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A 


TREATISE 


DISLOCATIONS 


AND 


FRACTURES    OF    THE  JOINTS 


By  sir  ASTLEY  COOPER,  BART.,  F.R.S., 

SERGEANT-SURGEON  TO    THE   KING,   »fec,   &€,  &C. 


Second  American  from  the  sixth  London  edition. 


REVISED  AND  GREATLY  IMPROVED  WITH  THE  ADDITION  OF  NUMEROUS 
AND  VALUABLE  ILLUSTRATIONS. 


TO    WHICH    ARE     ADAPTED  THE 
NOTES  AND  REFERENCES  TO  THE  FIRST  AMERICAN  EDITION, 

By  THE  LATE  JOHN  D.  GODMAN,  M.D. 
Lecturer  on  Anatomy  and  Physiology,  Professor  of  Physiology  in  the  Philadelphia 
Museum,  Member  of  the  Academy  of  Natural  Sciences,  &c,  &,c 


BOSTON: 

LILLY   &    WAIT    AND    CARTER    &  HENDEE. 

N.  YORK,  G.  &  C.  »fe  H.  CARVILL  &  E.  BLISS  ;  ALBANY,  LITTLE  &  CUM- 
MINGS;  PHILADELPHIA,  CARY  &  HART  ;  NEW  ORLEANS, 
M.  CARROLL  ;  PORTLAND,  S.  COLMAN. 

1832. 


Entered  according  to  Act  of  Congress,  la  the  year  1832, 
By  Lilly  &  Wait, 
In  the  Clerk's  Office  of  the  District  Court  of  Massachusetts. 


^  17.  )^ 

TO     THE  ^ 

STUDENTS    OF    ST    THOMAS'S  AND 
GUY'S  HOSPITALS. 


My  Dear  Young  Friends, 

This  Work  has  been  composed  for  your  use  ; 
and  if  you  derive  advantage  from  it,  my  principal 
object  will  be  attained.  I  cannot,  however,  omit 
this  opportunity  of  expressing  my  gratitude  for  the 
affectionate  and  respectful  manner  in  which  you 
have  always  received  me  as  your  instructer.  Your 
parents  and  relatives,  many  of  whom  were  my 
pupils,  are  also  entitled  to  my  most  grateful  acknow- 
ledgments ;  they  fostered  me  in  early  life  ;  and  by 
their  friendship  and  recommendation  have  largely 
contributed  to  procure  to  me  a  degree  of  success 
which,  I  fear,  is  beyond  my  merits,  and  a  course  of 
uninterrupted  happiness  which  few  have  been  per- 
mitted to  enjoy. 

Believe  me,  always. 

Your  affectionate  Friend, 

AsTLEY  Cooper. 


PREFACE    TO    THE    FIFTH  EDITION. 


It  is  incumbent  on  me  to  observe,  that  although 
I  believe  the  matter  of  this  Work  to  be  correct,  and 
regard  it  as  the  result  of  a  considerable  share  of 
experience,  jet  I  am  aware  that  the  reader  may  de- 
tect a  too  familiar  mode  of  expression,  and  may 
censure  me  for  want  of  attention  to  its  style.  The 
familiarity  of  the  diction  arises  from  my  desire  to 
be  perspicuous.  I  prefer  plain  and  simple  language 
to  an  elaborate  and  ostentatious  phraseology,  just  as 
J  would  a  good  plain  suit  to  the  finest  embroidered 
dress ;  and  am  ready  to  own,  that  my  thoughts  are 
more  steadfastly  directed  to  the  matter  which  1 
give,  than  to  the  manner  in  which  it  is  conveyed. 

I  am  much  indebted  to  my  friends  for  their  com- 
munications ;  the  life  of  man  is  too  short  to  allow 
him,  even  with  the  greatest  industry,  zeal,  and  with 
the  most  advantageous  opportunities,  to  witness  all 
the  varieties  of  accident  or  disease  ;  and  I  should 
feel  that  I  wa^  not  properly  discharging  my  duty,  if 
I  omitted  to  avail  myself  of  all  the  evidence  which 


vi 


PREFACE. 


might  be  adduced  by  those  on  whose  respectable 
testimony  I  could  depend. 

While,  then,  I  sincerely  thank  my  friends  for  their 
kindness,  I  wish  to  state  to  them  and  to  others,  that 
they  will  always  oblige  me,  by  giving  me  any  infor- 
mation which  it  is  in  their  power  to  convey  upon 
this  or  any  other  subject  in  surgery. 

In  looking  over  the  following  pages  on  disloca- 
tions, I  feel  that  my  professional  brethren  will  be 
disposed  to  think  that  I  have  limited  to  too  short  a 
period  the  attempts  at  reduction.  It  has  been 
stated,  that  dislocations  have  been  reduced  at  four 
and  even  six  months  after  the  injury,  and  this  as- 
sertion I  am  not  disposed  to  deny ;  indeed,  I  have 
myself  had  an  opportunity  of  witnessing  examples 
of  the  fact ;  but,  excepting  in  very  emaciated,  re- 
laxed, and  aged  persons,  I  have  observed  that  the 
injury  done  in  ^he  extension,  has  been  greater  than 
the  advantage  received  from  the  reduction;  and, 
therefore,  in  the  case  of  a  very  strong  musculai: 
person,  I  am  not  disposed,  after  three  months,  to  re- 
commend the  attempt,  finding  that  the  use  of  the 
limb  is  not,  when  reduced,  greater  than  that  which 
it  would  have  acquired  in  its  dislocated  state.  Let 
this  be  fairly  represented  to  the  patient ;  and  then, 
at  his  request  only,  the  reduction  should  be  attempt- 
ed :  but,  '  with  all  appliances  and  means  to  boot,' 
the  extension  must  be  very  gradually  made,  and 
without  violence,  to  avoid  injury  to  the  muscles  and 
nerves. 


PREFACE. 


vli 


I  have  stated,  that  in  fractures  of  the  upper  part 
of  the  thigh-bone,  the  foot  is  generally  everted  ;  to 
which  there  is  sometimes  an  exception  ;  for  I  have 
seen  a  case  of  Mr  LangstafFs,  surgeon  in  the  city, 
in  which  the  foot  was  inverted,  and  the  bones,  al- 
though they  rubbed  against  each  other,  had  not 
united. 

Mr  Guthrie  considers  it  probable,  that  the  inver- 
sion of  the  foot  in  fractures  of  the  upper  part  of 
the  thigh-bone,  which  now  and  then  happens,  arises 
from  a  diagonal  fracture  through  the  trochanter 
major.  The  gluteus  medius  and  minimus,  with  the 
tensor  vaginse  femoris,draw  the  thigh-bone  forw^ards, 
and  roll  it  inwards.  He  showed  me  a  preparation 
which  confirmed  this  opinion. 

I  have  received  from  Mr  Brindley,  surgeon  of 
Wink  Hill,  an  account  of  a  dislocation  of  the  os 
femoris,  which  the  patient  is  able  to  produce  and  re- 
duce when  he  chooses  ;  the  man  is  fifty  years  of 
age.  Mr  Morley,  of  Uttoxeter,  has  transmitted  to 
me  a  case  of  compound  fracture  of  the  head  of  the 
OS  humeri:  the  end  of  the  bone  was  sawn  off,  the 
bone  reduced,  and  the  patient  did  well ;  the  length 
of  the  limb  differed  but  little  from  that  of  the  other. 
And  Mr  White,  of  the  Westminster  Hospital,  has 
shown  me  a  case  of  dislocation  of  the  os  femoris 
from  ulceration,  in  which  the  head  of  the  femur 
was  sawn  off,  and  the  person  recovered. 

I  have  been  accused  of  publishing  doctrines,  re-^ 
specting  fractures  of  the  neck  of  the  thigh-bone, 


viii 


PREFACE. 


which  differ  from  those  of  my  medical  brethren,  and 
this  I  am  perfectly  ready  to  acknowledge  ;  on  the 
other  hand,  I  have  heard  that  I  am  abused  for  not 
having  admitted  that  others  had  previously  given 
similar  opinions.  To  this  animadversion  I  have 
only  to  reply,  that  I  began  to  deliver  lectures  in  the 
year  1792,  and  that  I  never  failed  in  them  to  give 
publicity  to  the  opinions  which  I  have  here  advanc- 
ed. I  have  procured  early  copies  of  my  lectures, 
taken  by  some  of  my  students,  and  could  obtain  a 
great  number  of  others,  which  show  that  my  opinions 
of  non-union  were  those  which  the  present  volume 
contains.  By  a  comparison  of  the  dates  of  my  lec- 
tures, with  that  of  the  publication  alluded  to,*  it 
will  be  readily  seen  who  had  the  priority  in  forming 
those  opinions. 

UNION  OF   THE  FRACTURED  CERVIX. 

The  earliest  notes  of  my  lectures  (and  my  first 
lectures  were  given  in  1792),  were  in  these  terms ;  — 

FRACTURES   OF  THE  THIGH  BONE  AT  ITS  CERVIX. 

'These  fractures  seldom,  if  ever,  become  after- 
wards united,  for  which  two  reasons  may  be  given ; 
firsts  that  the  uniting  matter  is  thrown  into,  and  lost 
in  the  joint ;  and,  secondly^  that  the  fractured  por- 

*  Principles  of  Surgery  by  John  Bell,  published  in  1801. 


PREFACE. 


ix 


tions  of  the  bone  are  not  in  apposition,  the  thigh- 
bone being  drawn  from  its  head  (which  still  re- 
mains in  its  socket)  by  the  action  of  the  glutei 
muscles.' 

Extract  from  Sir  Astley  Cooper^s  Surgical  Lectures^ 
delivered  in  the  year  1 793,  taken  from  the  notes  of 
Mr  Fiske. 

*  When  a  bone  which  forms  part  of  a  joint  is 
fractured  transversely,  union  seldom  takes  place  be- 
tween the  fractured  ends,  as  in  the  patella  and  ole- 
cranon ;  where  the  same  effusion  of  blood  takes 
place,  but  is  lost  in  the  cavity  of  the  joint,  from 
which  it  receives  vessels,  and  becomes  of  a  liga- 
mentous substance.  When  the  cervix  of  the  os  fe- 
moris  is  fractured,  it  becomes  united  to  the  capsular 
ligament  by  bands  :  the  reason  for  this  kind  of  union 
taking  place  is  exactly  the  same  as  in  a  trepanned 
skull;  for  the  action  of  the  muscles  inserted  into 
the  upper  part  of  the  bone  draws  it  upwards,  and 
those  into  the  lower  part  draw  it  downwards,  and 
the  space  becomes  too  great  for  the  vessels  of  the 
bone  to  shoot  into  the  coagulated  blood  and  form 
it  into  bone.  This,  I  think,  will  hold  good,  though 
it  is  different  from  the  opinion  of  many  men.' 

Charles  Fiske. 

Saffron  Walden^ 

JVov,  Uth,  1824. 
2 


X 


PREFACE. 


From  Mr  Ltikyn,  of  Faversham. 

Dear  Sir :  —  I  am  sorry  to  say  that  my  notes  on 
your  surgical  lectures,  delivered  in  1793,  are  very 
short  ;  in  the  one  on  simple  fractures  you  said, 
*  There  are  some  fractures  that  happen  in  joints 
that  never  unite,  as  in  the  neck  of  the  thigh-bone  ; 
the  blood  is  extravasated  into  the  joint,  and  only 
ligamentous  matter  deposited,  the  vessels  shooting 
into  the  coagulum  coming  from  the  ligament.  Ano- 
ther reason  is,  the  parts  cannot  be  kept  in  ap- 
position.' 

I  remain,  dear  Sir, 
Faversham,  Your  very  obedient  servant, 

JVov.  \2th,  1824.  Robert  Lukyn. 

From  Dr  Pidcock^  of  Watford, 

My  dear  Sir :  —  In  a  copy  I  made  of  the  lecture 
on  simple  fractures  there  is  this  brief  remark  on  the 
subject  of  your  inquiry :  '  In  fractures  of  the  cervix 
femoris  the  ends  of  the  bone  are  never  opposite  to 
each  other  ;  the  callus  is  thrown  into  the  acetabulum, 
and  union  never  takes  place.' 

Watford,  I  remain  very  faithfully  your's, 

JYov.  \4th,  lcJ24.  John  Pjdcock. 

Pupil  in  1794-5. 


PREFACE. 


From  Mr  Pulley^  of  Bedford, 

Dear  Sir :  —  I  send  jou  with  much  pleasure  your 
observations  on  fractures  of  the  neck  of  the  thigh- 
bone. You  will  find  my  language  incorrect  in  some 
parts,  owing  to  the  hurry  of  transcribing,  arising 
from  the  multiplicity  of  matters  then  to  be  attended 
to ;  but  I  can  vouch  for  the  accuracy  of  the  state- 
ment, and  had  much  rather  send  you  an  exact  copy 
of  the  lecture  now  in  my  possession,  not  knowing 
the  reason  of  your  present  application. 

*  Fracture  of  the  neck  of  the  thigh-bone.  —  This 
fracture  never  unites  ;  tell  the  patient  this,  and  that 
he  must  be  lame  for  life.  When  the  injury  happens 
with  persons  not  more  than  fifty-five  years  of  age, 
the  recovery  may  be  so  far  that  the  patient  may  be 
able  to  walk  with  a  stick ;  but  should  it  happen 
with  very  old  people,  they  will  never  after  be  able 
to  walk  out  without  crutches.  The  fractured  cer- 
vix does  not  unite,  because  the  extravasated  matter, 
or  coagulable  lymph  thrown  out  for  union,  is  lodged 
in  the  joint,  so  that  it  is  not  applied  to  the  ends  of 
the  bone  ;  besides,  union  cannot  be  effected,  as  the 
ends  of  the  bones  are  so  far  removed  from  each 
other.  Attempts  have  frequently  been  made  to  ef- 
fect a  union,  but  they  have  never  succeeded.' 
I  remain,  dear  Sir, 

Bedford^  Your  most  obedient  servant, 

JVov.  \2th,  1824.  John  Pulley. 

Pupil  in  1796. 


Xii  PREFACE. 

From  Mr  Weekes,  of  Hurst-per-Pdint,  Sussex. 

Dear  Sir  :  —  I  am  sorry  I  have  been  prevented 
ansv^ering  your  letter  before  ;  but  upon  referring  to 
your  lectures,  I  find  the  •  following  observations, 
viz  :  — 

*  Of  fracture  of  the  cervix  femoris.  —  This  is  of 
frequent  occurrence,  but  seldom  if  ever  happening 
but  in  people  of  advanced  age.  These  fractures 
are  often  supposed  to  be  cured,  but  in  reality  they 
never  are.  People,  after  these  fractures,  should  al- 
w^ays  w^alk  w^ith  a  stick  ;  and  if  they  are  stout  and 
fat,  crutches  are  admissible. 

'  The  reason  why  fractures  of  the  cervix  femoris 
do  not  get  w^ell  so  soon  as  fractures  of  the  trochan- 
ter is,  that  in  the  former  the  callus  becomes  extra- 
vasated  in  the  joint,  and  renders  union  of  the  bone 
impracticable.' 

I  remain,  dear  Sir, 

Your  very  humble  servant, 
Hurst-per-Pomt,  H.  Weekes. 

Sussex, 

Pupil  in  1796. 

From  Mr  Overend,  of  Sheffield, 

Dear  Sir .  —  In  referring  to  my  notes  of  your 
lectures  on  fracture  of  the  cervix  femoris,  delivered 


PHEFACE.  xiii 

in  the  year  1 797,  I  find  the  following  observations. 
After  describing  the  appearances  indicating  the  frac- 
ture of  this  part  of  the  thigh-bone,  my  notes  state  — 

'  A  crepitus  in  fracture  of  the  cervix  femoris  can 
never  be  observed,  originating  from  the  tv^^o  extre- 
mities of  the  broken  bone  never  being  in  contact, 
and,  consequently,  a  bony  union  never  takes  place : 
in  the  first  instance,  from  the  want  of  contact ;  and, 
secondly,  from  extravasation  surrounding  the  affect- 
ed part,  which  progressively  becomes  vascular,  and 
forms  a  ligamentous  union,  if  union  at  all' 

Your  obedient,  humble  servant, 

Sheffield^  Hall  Overend. 

JVov.  \4th,  1824. 

Dr  Jeffries,  of  Liverpool,  took  the  following  JYotes  of 
my  Lectures  in  the  year  1797. 

'  In  the  cervix  femoris,  a  union  never  takes  place  ; 
the  leg  is  much  the  shortest,  the  foot  and  knee  turn- 
ed outwards,  and  great  motion  at  the  hip-jdint :  oc- 
curs only  in  old  people.  The  fractured  surfaces 
become  smooth  by  callus,  but  no  union  ever  follows, 
because  the  two  pieces  of  bone  are  never  applied, 
and  the  callus  matter  is  lost  within  the  cavity  of  the 
joint.' 


xiv 


PREFACE. 


From  Mr  Alexander,  of  Cor  sham,  Wilis, 

'  The  cervix  of  the  os  femoris  is  a  part  that  never 
unites.  It  is  an  accident  v^hich  generally  occurs  in 
old  people  after  the  age  of  fifty-six :  the  limb  be- 
comes shortened,  and  the  knee  and  foot  turned  out- 
wards. Ligamentous  matter  only  is  poured  out  into 
the  joint  and  around  the  head  of  the  bone.' 

Richard  H.  Alexander. 

Attended  in  1797-8-9;  believe  the  notes  were 
taken  in  1798. 

Fro7n  Mr  Rose,  of  High  Wycombe. 

Dear  Sir  :  —  I  am  sorry  to  have  been  prevented 
by  various  engagements  attending  to  your  request 
earlier,  in  sending  you  the  extract  from  the  lecture 
delivered  by  you,  on  the  subject  of  fracture  of  the 
cervix  of  the  os  femoris,  in  the  year  1798. 

*  The  reason  why  this  fracture  does  not  unite  :  — 
First,  ^  one  cause  is,  that  the  callus  is  effused  into 
the  cavity  of  the  joint :  secondly,  the  head  of  the 
bone  cannot  be  kept  in  apposition  with  the  cervix, 
which  explains  why  the  patient  is  always  lame.' 

Youthen  related  some  cases  published  by  Desault, 
wherein  he  stated  his  having  succeeded,  and  union 
had  taken  place  ;  but  as  they  were  in  young  sub- 


PREFACE. 


XV 


jects,  you  expressed  your  opinion,  that  they  were 
fractures  of  the  trochanter,  and  not  of  the  cervix. 

1  am,  dear  Sir, 
Your  faithful  and  obedient  servant. 
High  Wycombe,  William  Rose. 

Jlug.  30th,  1824. 


JYotes  on  Fracture  of  the  Neck  of  the  Thigh-Bone, 
taken  from  Sir  Astley  Cooperh  Lectures  in  1799, 
by  W,  Jackson. 

*  This  fracture  never  unites,  therefore  you  must 
inform  your  patients  they  will  always  be  lame.' 


.  The  expression  *  never  unites,'  is  a  little  too 
strong,  for  it  will  be  seen  in  my  work  that  I  have 
mentioned  certain  exceptions  in  which  such  union 
might  be  possible ;  but  still  lameness  is  a  never- 
failing  consequence.  It  may  be  also  stated,  that  in 
addition  to  the  two  causes  of  want  of  union  which 
I  have  mentioned,  there  is  a  third,  which  I  have 
much  dwelt  upon  in  this  work,  viz,  cessation  of  the 
supply  of  blood  to  the  head  of  the  bone,  excepting 
through  the  medium  of  the  ligamentum  teres,  cans- 


xvi 


PREFACE. 


ed  by  the  laceration  of  the  reflected  ligament  and 
periosteum. 

The  question  of  union  or  non-union  of  the  frac- 
ture of  the  neck  of  the  thigh-bone,  as  a  general 
principle,  involves  very  important  consequences  ;  as 
the  infirmity  w^hich  invariably  follows  these  acci- 
dents w^ould  expose  every  surgeon  in  the  kingdom 
to  an  action  for  neglect  or  w^ant  of  skill,  if  such 
fractures  were  really  capable  of  uniting,  so  as  to 
render  the  limb  firm,  and  prevent  the  lameness  which 
in  every  case  that  I  have  seen  was  the  uniform  re- 
sult, although  union  in  a  large  proportion  of  them 
was  attempted. 

If  I  were  called  upon  to  give  evidence  in  a  court 
of  justice  in  such  a  case,  I  should  say,  that  the  con- 
sequent lameness  was  not  imputable  to  any  want  of 
skill,  but  to  the  nature  and  seat  of  the  fracture,  as 
I  have  never  seen  an  instance  in  which  it  did  not 
occur.  But  to  those  who  hold  a  contrary  opinion, 
all  that  could  be  said  is,  '  you  have  exposed  yourself 
to  this  action  from  want  of  proper  attention  to  the 
issue  of  these  accidents,  and  are  culpable,  according 
to  the  very  doctrine  which  you  maintain.' 


Since  writing  the  above  observations,  I  have  re- 
ceived the  following  letter  and  case. 


PREFACE. 


xvii 


Dear  Sir  Astley  :  —  I  beg  to  forward  you  a  note 
of  a  case  of  fracture  within  the  capsular  ligament, 
which  fully  illustrates  your  opinion  of  the  nature  and 
consequences  of  that  injury.  I  have  abstained  from 
drawing  any  conclusions  on  the  case,  confining  my- 
self to  its  history  and  dissection.  The  bones,  not 
yet  subjected  to  any  preparation,  are  in  my  posses- 
sion, and  if  considered  as  worthy  a  place  in  the 
museum,  I  shall  feel  great  pleasure  in  forwarding 
them  to  you- 

I  am,  with  great  respect, 
Sheerness,  Your  obedient  servant, 

Dec.  Is/,  1824.  Arch.  Robertson. 

Case. —On  the  25th  of  June,  1822,  William 
Daruin,  aged  sixty-two,  a  tall,  athletic  convict,  of  a 
sanguine  temperament,  fell,  with  a  very  inconsider- 
able violence  across  a  piece  of  timber  in  the  Dock- 
yard, his  left  hip  coming  in  contact  with  the  wood. 
On  rising,  he  felt  an  acute  pain  in  the  region  of  the 
acetabulum,  but  no  other  inconvenience,  for  he  walk- 
ed on  board  to  exhibit  himself  to  the  surgery  man. 
From  finding  him  ranked  up  with  the  sick  of  the 
hulk  on  my  morning  visit  of  the  26th,  from  his  walk- 
ing on  board,  and  from  his  own  account  of  the  ac- 
cident, I  did  not  suspect  any  serious  injury  of  the 
joint,  and  treated  the  case  as  one  of  concussion. 
On  the  29th,  however,  he  complained  of  a  very  sud- 
den and  very  agonizing  accession  of  pain,  which 

induced  me  to  subject  him  to  a  more  critical  ex- 
3 


xviii 


PREFACE. 


amination.  No  evident  alteration  in  the  size  of 
either  hip  could  be  discerned,  but  a  shortening  of 
the  limb  was  conspicuous,  which  was  rendered  more 
evident  by  making  him  stand  on  the  sound  limb  ; 
extension  removed  this  difference,  but  on  being  freed 
from  restraint,  it  again  assumed  its  morbid  shape ; 
the  knee  and  foot  were  everted,  and  rotation  greatly 
increased  his  pain. 

I  removed  him  to  the  hospital  as  a  case  of  fracture 
within  the  capsule,  but  a  continued  attention  for  a 
period  of  six  months  to  position  (chiefly  with  the 
view  of  restraining  the  motion  of  the  pelvis  and  of 
securing  the  limb),  made  no  other  alteration  in  the 
symptoms  than  a  gradual  diminution  of  pain.  A 
pair  of  crutches  were  given  him,  he  was  placed  on 
the  invalid  list,  and  remained  so  till  the  26th  of 
December,  when  he  died  from  general  dropsy. 

On  dissection,  the  injury  proved  a  transverse  frac- 
ture of  the  head  of  the  femur  within  the  capsular 
ligament.  No  species  of  union  had  taken  place. 
The  upper  portion  of  the  fractured  bone  was  retain- 
ed in  situ  by  the  sound  ligament ;  tolerably  smooth 
on  its  surface,  but  without  any  ossific  deposit.  The 
lower  portion  very  irregular,  with  several  detached 
pieces  of  bone  adhering  to  the  insertion  of  the  cap- 
sular ligament.  Between  the  acetabulum  and  the 
portion  of  bone  retained  in  situ  by  the  ligament 
were  several  small  oval-shaped  loose  cartilaginous 
substances,  apparently  fragments  of  bone  ;  the  cap- 


PREFACE. 


xix 


sular  ligament  partially  lacerated,  in  a  line  above 
the  trochanter  major,  and  greatly  thickened  in  its 
insertions. 

Arch.  Robertson. 
Convict  Hospital  Ship,  Sheerness, 
]st  Dec,  1824. 


I  may  be  permitted  in  this  place  to  observe,  that 
I  have  just  added  to  the  collection  at  St  Thomas's 
Hospital,  a  fracture  of  the  patella,  in  which  the  por- 
tions of  bone  are  in  contact,  and  in  w^hich  an  ossific 
union  appeared  at  first  sight  to  have  been  produced 
that  might  have  w^arranted  such  an  inference  in  the 
living  body ;  yet  the  union  is  only  ligamentous. 

A.  C. 

December,  1824. 


CONTENTS. 


Page 

On  Dislocations  in  general,  24 
Particular  Dislocations,  66 
Dislocations  of  the  Hip-joint,  ib. 
Dislocation  upwards,  or  on  the  Dorsum  Ilii,  68 
Dislocation  downwards,  or  into  the  Foramen  Ovale ^  79 
Dislocation  backwards,  or  into  the  Ischiatic  Notch,  90 
Dislocation  on  the  Pubes,  101 
Fractures  of  the  Os  Innominatum,  113 
Fractures  of  the  Upper  Part  of  the  Thigh-Bone,  122 
Fractures  of  the  Neck  of  the  Thigh-Bone,  within  the  Cap- 
sular Ligament,  124 
Additional  Observations  on  Fractures  of  the  Neck  of  the 

Thigh-bone,  159 
Fractures  of  the  Cervix  Femoris,  external  to  the  Capsular 

Ligament,  and  into  the  Cancelli  of  the  Trochanter  Major,  163 

Fractures  through  the  Trochanter  Major,  175 

Fracture  of  the  Epiphysis  of  the  Trochanter  Major,  187 

Fractures  below  the  Trochanter,  189 

Dislocations  of  the  Knee,  191 

Dislocation  of  the  Patella,  193 

Dislocation  of  the  Patella  upwards,  196 

Dislocation  of  the  Tibia  at  the  Knee-joint,  198 
Partial  Luxation  of  the  Thigh-bone  from  the  Semilunar 

Cartilages,  202 

Dislocation  of  the  Knee-joint,  206 

Compound  Dislocation  of  the  Knee-joint,  208 

Dislocation  of  the  Knee  from  Ulceration,  210 

Fractures  of  the  Knee-joint,  212 

Fracture  of  the  Patella,  ib. 

Perpendicular  Fracture  of  the  Patella,  221 

Compound  Fracture  of  the  Patella,  224 


CONTENTS. 


Page 

Oblique  Fractures  of  the  Condyles  of  the  Os  Femoris  into 

the  Joint,  228 
Compound  Fracture  of  the  Condyles  of  the  Femur,  230 
Oblique  Fractures  of  the  Os  Femoris,  just  above  its  Con- 
dyles, 232 
Compound  Fracture,  just  above  the  Condyles  of  the  Os 

Femoris,  234 
Simple  Fracture  above  the  Condyles  of  the  Os  Femoris,  236 
Fracture  of  the  Head  of  the  Tibia,  239 
Dislocations  of  the  Head  of  the  Fibula,  240 
Dislocations  of  the  Ankle-joint,  242 
Simple  Dislocation  of  the  Tibia  inwards,  *  243 

Simple  Dislocation  of  the  Tibia  forwards,  -246 
Partial  Dislocation  of  the  Tibia  forwards,  247 
Simple  Dislocation  of  the  Tibia  outwards,  249 
Compound  Dislocation  of  the  Ankle-joint,  25! 
Compound  Dislocation  of  the  Tibia  inwards,  26 1 

Compound  Dislocation  of  the  Tibia  outwards,  262 
On  removing  the  Ends  of  the  Bones,  288 
Additional  Cases  of  Compound  Dislocation  of  the  Ankle-joint,  312 
Cases  which  render  Amputation  necessary,  317 
Fractures  of  the  Tibia  and  Fibula  near  the  Ankle-joint,  335 
Fracture  of  the  Tibia  at  the  Ankle-joint,  337 
Dislocation  of  the  Tarsal  Bones,  339 
Simple  Dislocation  of  the  Astragalus,  ib. 
Compound  Dislocation  of  the  Astragalus,  343 
Dislocation  of  the  Os  Calcis  and  Astragalus,  362 
Dislocation  of  the  Os  Cuneiforme  Internum,  357 
Dislocation  of  the  Toes  from  the  Metatarsal  Bones,  359 
Dislocations  of  the  liOwer  Jaw,  '  360 

Complete  Luxation  of  the  Jaw,  362 
Partial  Dislocation  of  the  Jaw,  365 
Subluxation  of  the  Jaw,  ib. 
Dislocations  of  the  Clavicle,  367 
Junction  of  the  Sternal  Extremity  of  the  Clavicle  with  the 
Sternum  ib. 


CONTENTS. 


xxiii 


Page 

Dislocation  of  the  Sternal  Extremity  of  the  Clavicle,  369 
Junction  of  the  Clavicle  with  the  Scapula,  373 
Dislocation  of  the  Scapular  Extremity  of  the  Clavicle,  375 
Dislocation  of  the  Clavicle,  with  Fracture  of  the  Acromion,  377 
Structure  of  the  Shoulder-joint,  379 
Dislocation  of  the  Os  Humeri,  383 
Dislocation  in  the  Axilla,  384 
Dislocation  forwards,  behind  the  Pectoral  Muscle,  and  be- 
low the  middle  of  the  Clavicle,  399 
Dislocation  of  the  Os  Humeri  on  the  Dorsum  Scapulae,  403 
Partial  Dislocation  of  the  Os  Humeri,  407 
Fracture  of  the  Neck  of  the  Os  Humeri,  with  the  Disloca- 
tion forwards  under  the  Pectoral  Muscle,  410 
Compound  Dislocation  of  the  Os  Humeri,  412 
Partial  Dislocation  of  the  Os  Humeri  forwards,  413 
Dislocation  of  the  Os  Humeri  backwards,  416 
Fractures  near  the  Shoulder-joint,  liable  to  be  mistaken  for 

Dislocations,  418 
Fractures  of  the  Acromion,  418 
Fracture  of  the  Neck  of  the  Scapula,  420 
Fracture  of  the  Neck  of  the  Os  Humeri,  422 
Structure  of  the  Elbow-joint,  425 
Dislocations  of  the  Elbow-joint,  429 
Dislocation  of  both  bones  backwards,  430 
Compound  Dislocation  of  the  Os  Humeri  at  the  Elbow- 
joint,  431 
Lateral  Dislocation  of  the  Elbow,  434 
Dislocation  of  the  Ulna  backwards,  436 
Dislocation  of  the  Radius  forwards,  437 
Dislocation  of  the  Radius  backwards,  441 
Lateral  Dislocation  of  the  Radius,  442 
Fractures  of  the  Elbow-joint,  443 
Fractures  above  the  Condyles  of  the  Humeri,  443 
Fracture  of  the  Internal  Condyle  of  the  Os  Humeri,"  446 
Fracture  of  the  External  Condyle  of  the  Os  Humeri,  447 
Fracture  of  the  Coronoid  Process  of  the  Ulna,  449 


CONTENTS. 


Page 

Fracture  of  the  Olecranon,  450 
Compound  Fracture  of  the  Olecranon,  •  457 

Fracture  of  the  Neck  of  the  Radius,  ib. 
Compound  Fractures  and  Dislocations  of  the  Elbow-joint,  458 
Structure  of  the  Wrist-joint,  462 
Dislocations  of  the  Wrist-joint,  464 
Dislocation  of  the  Radius  at  the  Wrist,  466 
Dislocation  of  the  Ulna,  467 
Simple  Fracture  of  the  Radius,  and  Dislocation  of  the  Ulna,  468 
Fracture  of  the  Lower  End  of  the  Radius,  without  Disloca- 
tion of  the  Ulna,  470 
Compound  Dislocation  of  the  Ulna,  with  Fracture  of  the 

Radius,  471 
Dislocation  of  the  Carpal  Bones,  474 
Compound  Dislocation  of  the  Carpal  Bones,  476 
Dislocation  of  the  Metacarpal  Bones,  479 
Fracture  of  the  Head  of  the  Metacarpal  Bones,  480 
Dislocations  of  the  Fingers  and  Toes,  482 
Dislocation  from  Contraction  of  the  Tendon,  483 
Dislocation  of  the  Thumb,  485 
Dislocation  of  the  Metacarpal  Bones  from  the  Os  Trapezium,  486 
Dislocation  of  the  First  Phalanx,  489 
Dislocation  of  the  Second  Phalanx,  492 
Dislocation  of  the  Ribs,  '  493 
Injuries  of  the  Spine,  495 
Concussion  of  the  Spinal  Marrow,  498 
Extravasation  in  the  Spinal  Canal,  499 
Fracture  of  the  Spine,  502 
Fractures  of  the  Bodies  of  the  Vertebrae,  with  Displacement,  504 
Inflammation  and  Ulceration  of  the  Spinal  Marrow,  511 


Plates  and  Explanations. 


A    TREATISE,  &c. 


DISLOCATIONS  IN  GENERAL. 


Definition,  —  A  dislocation  is  a  displacement  of 
the  articulatorj  portion  of  a  bone  from  the  surface 
on  which  it  was  naturally  received. 

JYecessity  of  prompt  assistance  ;  instances  of  mistake. 
—  Of  the  various  accidents  which  happen  to  the  body 
there  are  few  which  require  more  prompt  assistance, 
or  which  more  directly  endanger  the  reputation  of  a 
surgeon,  than  cases  of  luxation.  If  much  time  shall 
have  elapsed  before  the  attempt  at  reduction  is 
made,  the  difficulty  of  accomplishing  it  is  propor- 
tionably  increased,  and  not  unfrequently  becomes 
insuperable;  and  if  the  nature  of  the  injury  be  un- 
known, and  the  luxation  consequently  be  left  unre- 
duced, the  patient  will  remain  a  living  memorial  of 
the  surgeon's  ignorance  or  inattention.  '  What  is 
the  matter  with  me  V  said  a  patient  who  came  to 
my  house,  placing  himself  before  me  and  directing 
4 


26 


DtSLOCATlONS  IN  GENERAL. 


my  attention  to  his  shoulder:  '  Why,  Sir,  your  arm 

is  dislocated.'  —  '  Do  you'say  so !    Mr  told  me 

it  was  not  out.'  — '  How  long  lias  it  been  dislocated?' 
— '  Many  weeks,'  he  replied.  —  'Oh  then  you  had 
better  not  have  any  attempt  at  reduction  made.'  — 

He  said,  '  Well,  I  will  take  care  that  Mr  has 

no  more  bones  to  set ;  for  1  will  expose  his  ignorance 
in  that  part  of  the  country  in  which  I  live.'  —  He 
was  a  man  of  malevolent  disposition,  and  carried  his 
threat  into  execution,  to  the  great  injury  of  the  sur- 
geon, who  was  also  frequently  reminded  of  his  want 
of  skill,  by  meeting  his  former  patient  in  his  rounds; 
and,  what  was  worse,  by  hearing  the  following  ob- 
servation frequently  repeated:  '  Mr   is  a  good 

apothecary,  but  he  knows  nothing  of  surgery.' 

In  a  dislocation  of  the  os  femoris,  which  still  re- 
mains unreduced,  a  consultation  was  held  upon  the 
nature  of  the  injury,  and  after  a  long  consideration, 
a  report  was  made  by  one  of  the  surgeons  to  this 
effect :  '  Well,  Sir,  thank  God,  we  are  all  agreed 
that  there  is  no  dislocation.' 

Knowledge  of  anatomy  necessary,  —  A  considera- 
ble share  of  anatomical  knowledge  is  required  to 
detect  the  nature  of  these  accidents,  as  well  as  'to 
suggest  the  proper  means  of  reduction;  and  it  is 
much  to  be  lamented,  that  students  neglect  to  inform 
themselves  sufficiently  of  the  structure  of  the  joints. 
They  often  dissect  the  muscles  of  a  limb  with  great 
neatness  and  minuteness,  and  then  throw  it  away, 
without  any  examination  of  the  ligaments,  cartilages, 
or  ends  of  the  bones  ;  a  knowledge  of  which,  in  a 
surgical  point  of  view,  is  of  infinitely  greater  import- 
ance ;  and  from  such  negligence  arise  the  errors 
into  which  those  novices  fall  when  they  embark  in 
the  practice  of  their  profession;  for  the  dislocations 
of  the  hip,  the  elbow,  and  the  shoulder,  are  scarcely 
to  be  detected,  but  by  those  who  possess  accurate 


DISLOCATIONS   IN  GENERAL. 


27 


anatomical  information.  Even  our  hospital  surgeons, 
who  have  neglected  their  anatomy,  mistake  these 
accidents;  and  I  have  known  the  pulleys  applied  to 
an  hospital  patient,  in  a  case  of  fracture  of  tlie  neck 
of  the  thigh-bone,  which  had  been  mistaken  for  a 
dislocation,  and  the  patient  exposed,  through  the 
surgeon's  ignorance,  to  a  violent  and  protracted  ex- 
tension. It  is  therefore  proper,  that  the  form  of 
the  extremities  of  the  bones,  their  mode  of  articula- 
tion, the  ligaments  by  which  they  are  connected, 
and  the  direction  in  which  their  most  powerful  mus- 
cles act,  should  be  well  understood. 

Difficulty  from  tumefaction.  —  Yet  it  would  be  an 
injustice  not  to  acknowledge,  that  the  tumefaction 
arising  from  extravasation  of  blood,  and  the  tension 
resulting  from  the  inflammation,  which  frequently 
ensues,  will,  in  the  early  days  of  the  accident,  ren- 
der it  difficult  for  the  best  surgeon  perfectly  to  as- 
certain the  exact  extent  of  the  injury  ;  and,  there- 
fore, conclusions  drawn  at  a  time  when  the  muscles 
are  wasted,  and  the  swelling  is  dispersed,  when  the 
head  of  the  bone  can  be  distinctly  felt,  and  the  mo- 
tions of  the  limb  are  found  to  be  impeded  in  a  par- 
ticular direction,  if  they  tend  to  the  prejudice  of 
the  individual  who  may  have  given  a  different  opin- 
ion under  circumstances  so  much  less  favorable  for 
forming  a  correct  conclusion,  will  be  both  illiberal 
and  unjust. 

Symptoms.  —  The  immediate  effect  of  dislocation 
is  to  change  the  form  of  the  joint,  and  often  to  pro- 
duce an  alteration  in  the  length  of  the  limb;  to  oc- 
casion the  almost  entire  loss  of  motion  in  the  part 
after  the  muscles  have  had  time  to  contract,  and  to 
alter  the  axis  of  the  limb.  This  altered  position  of 
the  limb  has  been  attributed,  by  some  surgeons,  to 
the  influence  of  the  remaining  portion  of  ligament; 
but,  in  every  accident,  the  direction  of  the  bone  is 


28 


DISLOCATIONS    IN  GENERAL. 


too  much  the  same  to  induce  the  beh'ef  that  it  is 
chiefly  the  effect  of  muscular  influence;  for  the  hga- 
ment  is  extensivelj  torn,  in  most  cases  scarcely  any 
portion  of  it  remaining  whole,  particularly  in  disloca- 
tions of  the  thigh,  yet  the  position  of  the  limb  under 
the  different  species  of  dislocation  is  found  subject 
to  little  variation.  The  form  of  the  bone  has,  how- 
ever, some  influence  on  its  future  position:  for  in 
fractures  of  the  neck  of  the  thigh-bone,  the  knee  is 
turned  outwards;  while  in  dislocations,  it  is  turned 
inwards;  a  difference  which  arises  from  the  greater 
capacity  of  the  bone  to  roll  upon  its  axis  when  the 
neck  is  broken. 

In  the  first  moments,  however,  of  the  dislocation, 
considerable  motion  remains,  and  the  position  is  not 
so  determinately  fixed  as  it  afterwards  becomes;  for 
1  have  seen  a  man  brought  into  Guy's  Hospital,  who, 
but  a  few  minutes  before,  had  the  thigh-bone  dislo- 
cated into  the  foramen  ovale,  and  I  was  surprised  to 
find  in  a  case  otherwise  so  well  marked,  that  a  great 
mobility  of  the  bone  still  existed  at  the  dislocated 
part;  but  in  less  than  three  hours,  it  became  firmly 
fixed  in  its  new  situation  by  the  permanent,  or,  as  it 
is  called,  tonic  contraction  of  the  muscles. 

Length  of  limb  altered;  effusion  of  blood,  —  In 
some  dislocations  the  limb  is  rendered  shorter,  and 
thus  the  muscles  influenced  by  it  are  immediately 
thrown  into  a  state  of  relaxation;  but  if  the  limb 
be  elongated,  the  tension  of  the  principal  muscles 
around  the  joint  is  extreme,  and  they  are  sometimes 
stretched  to  laceration.  Blood  is  often  effused  in 
considerable  quantity  around  the  joint,  which  ren- 
ders detection  of  the  accident  difficult;  the  swelling 
being  sometimes  so  considerable  as  to  conceal  entire- 
ly the  ends  of  the  bones.  This  effusion  is  in  pro- 
portion to  the  size  and  number  of  the  vessels  lace- 
rated. 


DISLOCATIONS  IN  GENERAL.  29 

Eff'ects  of  pressure  from  the  dislocated  hone.  —  A 
severe  but  obtuse  pain  arises  from  the  pressure  of 
the  head  of  the  bone  upon  the  muscles,  and,  in  some 
cases,  this  pain  is  rendered  more  acute  from  its 
pressure  upon  a  large  nerve.  From  this  cause  also 
is  produced  a  paralysis  of  the  parts  below,  instances 
of  which  occur  in  dislocations  of  the  shoulder.  In 
other  cases,  the  bone  presses  upon  important  parts, 
so"  as  to  produce  effects  dangerous  to  life.  I  have 
for  many  years  mentioned,  in  my  lectures,  a  case  of 
a  dislocated  clavicle,  pressing  upon  the  oesophagus, 
so  as  to  endanger  life  ;  of  which  Mr  Davie,  of 
Bungay,  was  so  kind  as  to  send  me  an  account.  J 
shall  give  a  more  detailed  history  of  this  case  here- 
after. 

Criteri07i  of  the  accident  by  rotation. — In  most 
dislocations,  the  head  of  the  bone  may  be  readily 
felt  in  its  new  situation  ;  and  the  rotation  of  the  limb 
best  discovers  the  nature  of  the  accident,  as,  by  this 
movement,  the  head  of  the  bone  is  found  to  roll. 
The  natural  prominences  of  the  dislocated  bone,  in 
some  instances,  either  disappear,  or  become  less  con- 
spicuous,—  as  the  trochanter  in  luxations  of  the  hip- 
joint;  but  the  contrary  result  ensues  in  dislocations 
of  the  elbow;  for  there  the  olecranon  is  more  than 
usually  prominent,  and  serves  as  the  principal  guide 
for  discovering  the  nature  of  the  injury. 
.  Crepitus.  —  The  more  remote  eft'ects  of  the  acci- 
dent are,  that  frequently  a  sensation  of  crepitus  is 
produced  by  the  effusion  of  adhesive  matter  (fibrin) 
into  the  joint*  and  bursas;  the  synovia  becomes  in- 
spissated, and  crackles  under  motion,  a  circumstance 
of  which  every  practitioner  should  be  aware,  as  he 
may  be  otherwise  induced  erroneously  to  suspect  the 
existence  of  fracture. 

Infiammation  and  suppuration.  —  The  degree  of 
inflammation  which  succeeds  to  these  accidents  is 


30 


DISLOCATIONS  IN  GENERAL. 


generally  slight ;  but  in  some  cases  it  becomes  so 
considerable  as  to  produce  a  tumefaction,  which, 
added  to  that  resulting  from  extravasation  of  blood, 
frequently  renders  the  detection  of  the  injury  ex- 
ceedingly difficult.  Sometimes,  after  the  reduction 
of  dislocations,  suppuration  ensues,  and  the  patient 
falls  a  victim  to  excessive  discharge  and  irritation. 
Mr  Howden,  who  was  one  of  our  most  intelligent 
apprentices  at  Guy's  Hospital,  and  was  afterwards 
surgeon  in  the  army,  related  the  following  case: — 
'A  man  had  his  thigh  dislocated  upwards  and  back- 
wards on  the  ilium,  which  was  soon  after  reduced; 
the  next  dav  a  considerable  swellino:  was  observed 
on  the  part,  which  continued  to  increase,  accompa- 
nied with  rigors,  and  in  four  days  the  patient  died. 
On  dissection,  the  capsular  ligaments,  and  ligamen- 
tum  teres,  were  found  entirely  torn  away,  and  a  con- 
siderable quantity  of  pus  extravasated  in  the  sur- 
rounding parts.'  See  JMinutes  of  the  Physical  So- 
ciety^ Guyh  Hospital,  JYovember  12,  1791.  —  I  attend- 
ed the  master  of  a  ship,  who  had  dislocated  his 
thigh  upwards;  an  extension  was  made,  apparently 
with  success;  but  in  a  few  days  a  large  abscess  form- 
ed on  the  thigh,  which  destroyed  the  patient ;  for- 
tunately, however,  such  a  result  is  by  no  means  com- 
mon. 

When,  from  length  of  time,  or  any  other  cause, 
the  reduction  of  the  limb  is  rendered  impracticable, 
the  bone  forms  for  itself  a  new  bed,  and  some  de- 
gree of  motion  is  gradually  recovered;  although  in 
neglected  dislocations  of  the  lower  extremity,  the 
patient  is  ever  after  lame ;  and  in  those  of  the  up- 
per, the  motion  and  power  of  the  limb  are  very 
much  diminished. 

j^ppearances  on  dissection ;  ligaments,  —  On  ex- 
amination of  the  bodies  of  persons  who  die  in  con- 


DISLOCATIONS    IN  GENERAL. 


31 


sequence  of  dislocations  arising  from  violence,  the 
head  of  the  bone  is  found  completely  removed  from 
itssocket.  Thecapsular  ligament  is  torn  transversely  to 
a  great  extent:  the  peculiar  ligaments  of  joints,  as  the 
ligamentum  teres  of  the  hip,  are  torn  through;  but 
the  tendon  of  the  biceps,  in  dislocations  of  the  os 
humeri,  remains  uninjured,  as  far  as  I  have  been 
able  to  ascertain  by  dissection ;  although  I  would 
by  no  means  be  understood  to  say  that  this  is  uni- 
versally the  case. 

Tendons, —  The  tendons  which  cover  the  liga- 
ments are  also  torn  ;  as  the  tendon  of  the  subscap- 
ularis  muscle,  in  the  dislocation  in  the  axilla;  and 
according  to  the  extent  of  this  laceration,  is  the  fa- 
cility with  which  the  accident  recurs  after  reduction; 
a  circumstance  frequently  very  difficult  to  obviate. 

Muscles, —  The  muscles  also  are  influenced  by  the 
nature  of  the  accident,  being  in  some  cases  put  upon 
the  stretch,  even  to  laceration;  as  the  pectineus  and 
abductor  brevis,  in  dislocations  of  the  thigh  down- 
ward ;  "and  large  quantities  of  blood  become  extraj 
vasated  into  the  cellular  membrane. 

Dissections  of  old  dislocations,  8rc,  —  The  appear- 
ance of  joints  which  have  long  been  dislocated,  de- 
pends not  only  on  the  length  of  time  that  has  elap- 
sed from  the  accident,  but  also  on  the  structure  upon 
which  the  head  of  the  dislocated  bone  is  thrown  ; 
for  if  it  be  found  embedded  in  muscle,  its  articular 
cartilage  remains,  and  a  new  capsular  h'gament  forms 
around  it,  which  does  not  adhere  to  its  cartilaginous 
surface.  This  ligament,  in  d  slocations  of  the  femur, 
contains  within  it  the  head  of  the  bone,  with  the 
lacerated  portion  of  the  ligamentum  teres  united  to 
it.  (See plate,)  In  these  instances  the  bones  them- 
selves undergo  little  change.  The  capsular  ligament 
is  formed  from  the  surrounding  cellular  tissue  ;  which, 
being  pressed  upon  by  the  head  of  the  bone,  be- 


32 


DISLOCATIONS  IN  GENERAL. 


eomes  inflamed,  thiclcened,  and  condensed.  By  this 
means  a  substance  is  produced  somewhat  less  dense 
than  original  ligament,  but  still  possessing  sufficient 
firmness  to  bear  considerable  pressure,  and  to  fur- 
nish some  degree  of  support. 

Head  of  the  bone  resting  oti  another  bone,  Src,  —  But 
if  the  head  of  the  dislocated  bone  be  placed  on  the 
surface  of  another  bone,  or  upon  a  thin  muscle  over 
it,  that  muscle  becomes  absorbed,  and  the  bone  un- 
dergoes a  remarkable  change  ;  thus  it  is  found,  if 
the  dislocation  be  not  reduced,  that  both  the  ball 
and  the  bone  which  receives  it  are  changed  in  their 
form.  The  pressure  of  the  head  of  the  bone  pro- 
duces absorption  of  the  periosteum,  and  of  the  ar- 
ticular cartilaginous  surface  of  the  head  of  the  bone; 
a  cmooth  hollow  surface  is  formed,  and  the  ball  be- 
comes altered  in  its  shape  to  adapt  it  to  its  new  sur- 
face ;  and  whilst  this  absorption  proceeds  upon  the 
part  on  which  the  head  of  the  bone  rests,  an  ossific 
deposit  takes  place  around  it  from  the  periosteum, 
which  is  there  irritated,  but  not  absorbed.  '  'By  the 
deposition  of  this  bony  matter  between  the  perios- 
teum and  the  original  bone,  a  deep  cup  is  formed  to  re- 
ceive the  head  of  the  bone  ;  and  perhaps  no  instan- 
ces can  be  adduced  which  more  strongly  mark  the 
powers  of  nature  in  changing  the  form  of  parts  to 
accommodate  them  to  new  circumstances,  than  these 
effects  of  dislocation.    (^See  plates  2,  3,  and  4.) 

The  new  cup  which  is  thus  formed,  sometimes  so 
completely  surrounds  the  neck  of  the  bone,  as  to 
prevent  its  being  separated  without  fracture  (see 
plate)  ;  and  the  socket  is  smoothed  upon  its  internal 
surface,  so  as  to  leave  no  projecting  parts  which  can 
interrupt  the  motion  of  the  bone  in  its  new  situation. 

The  muscles  losing  their  action,  become  diminish- 
ed in  bulk,  and  reduced  in  their  length,  in  proportion 
to  the  displacement  of  the  bone  towards  their  ori- 


DISLOCATIONS  IN  GENERAL. 


33 


gin;  and  if  the  dislocation  has  been  long  unreduced, 
they  lose  their  flexibilitj,  and  tear  rather  than  yield 
to  extension. 


Dislocations  from  relaxation.  —  Although  disloca- 
tions happening  from  violence  are  accompanied  by 
laceration  of  the  ligaments  of  the  joint,  yet  they  may 
occur  from  relaxation  of  the  ligaments  only,  of  which 
the  following  case  is  an  example. 

Case,  —  A  girl  came  to  my  house  who  had  the 
power  of  throwing  her  patellae  from  the  surfaces  of 
the  condyles  of  the  os  femoris.  Her  knees  were 
bent  considerably  inwards;  and  when  the  rectus 
muscle  acted  upon  the  patella,  it  was  drawn  from 
the  thigh-bone  into  a  line  with  the  tubercle  of  the 
tibia,  and  laid  nearly  flat  upon  the  side  of  the  ex- 
ternal condyle  of  the  femur.  She  came  from  the 
south  of  Europe,  where  she  had  been  brought  up  as 
a  dancing  girl  from  her  earliest  years,  gaining  her 
daily  bread,  as  we  see  children  in  the  streets  of  Lon- 
don, by  dancing  upon  elevated  platforms;  and  she 
imputed  to  these  continued  and  early  exertions  the 
weakness  under  which  she  laboured. 

Dislocation  from  accumulation  of  Synovia.  —  A  si- 
milar relaxation  of  ligaments,  is  also  produced  by  an 
accumulation  of  synovia  in  joints.  Mr  Shillito,  sur- 
geon at  Hertford,  requested  me  to  see  a  female  do- 
mestic belonging  to  a  family  in  ray  neighbourhood, 
who  had  a  great  enlargement  of  the  knee-joint  from 
an  inordinate  secretion  of  synovia;  and  when  this 
became  absorbed,  the  ligaments  remained  so  much 
relaxed,  that  the  efforts  of  the  muscles  in  walking 
dislocated  the  patella  outwards.  I  ordered  her  into 
the  hospital,  that  the  students  might  observe  this 
case,  of  which  the  following  is  an  account. 
5 


34 


DISLOCATIONS  IN  GENERAL. 


Case  ;  dislocation  from  relaxation,  —  Ann  Parish 
was  admitted  into  Guy's  Hospital  in  the  autumn  of 
1810,  for  a  dislocation  of  the  left  patella  from  re- 
laxation of  the  ligaments.    She  had  for  four  years 
previously  a  large  accumulation  of  synovia  in  that 
knee,  causing  some  pain,  and  much  inconvenience  in 
walking.    Blisters  had  been  applied  without  much 
effect,  and  other  means  tried  for  four  montlis  before 
her  admission.    When  the  knee  had  acquired  con- 
siderable size,  the  swelling  spontaneously  subsided, 
and  she  then  first  discovered  that  the  patella  be- 
came dislocated  when  she  extended  the  limb.  She 
suffered  some  pain  whenever  this  happened,  and  she 
lost  the  power  of  the  limb  in  walking,  so  that  she 
fell  when  the  patella  slipped  from  its  place,  which 
it  did  whenever  she  attempted  to  walk  without  a 
bandage.    Tlie  patella  was  placed  upon  the  external 
condyle  of  the  os  femoris,  when  thrown  from  its  na- 
tural situation,  to  which  it  did  not  return  without 
considerable  pressure  of  the  hand.    In  other  re- 
spects her  health  was  good.    Straps  of  adhesive 
plaster  were  ordered  to  be  applied,  and  a  roller  to 
to  be  worn,  which  succeeded  in  preventing  the  dis- 
location so  long  as  they  were  used,  but  the  bone 
again  slipped  from  its  place  whenever  they  were 
removed.    \  knee-cap,  made  to  lace  over  the  joint, 
was  ordered  for  her.^ 

*  A.very  interesting  case  of  spontaneous  dislocation  from  re- 
laxation of  the  ligaments  is  related  by  Dr  Osborne  of  Cork,  in 
the  Edin.  Med.  and  Surg.  Journal  for  Oct.  1810.  The  patient 
when  about  to  embark  with  his  regiment  was  suddenly  seized 
with  so  violent  a  pain  in  his  side  as  to  disable  him  entirely,  and 
the  staff  physicians  were  of  opinion  that  his  liver  was  badly  dis- 
eased, fie  was  sent  to  his  father  in  Ireland,  where  he  was 
seen  by  Dr  Osborne,  who  found  him  in  a  state  of  great  emacia- 
tion and  debility;  the  liver  being  sensibly  enlarged,  and  feeling 
tough  and  doughy.  His  urine  was  scanty  and  deposited  a  sedi- 
ment, between  red  and  white,  in  colour.    '  His  right  leg  was 


DISLOCATIONS  IN  GENERAL. 


35 


Paralysis.  —  Dislocation  sometimes  arises  from  a 
loss  of  muscular  power  ;  for  when  the  muscles  are 
kept  long  and  forcibly  extended,  their  tone  becomes 
destroyed  ;  or  if,  from  a  paralytic  affection,  they 
lose  their  action,  a  bone  may  be  dislocated  easily, 
but  is  as  readily  replaced:  of  the  first  of  these  two 
causes,  the  following  case  is  an  illustration. 

Case,  —  Mr.  ,  a  gentleman  now  residing  in 

the  City,  passed  some  of  his  early  life  in  the  East 
Indies  ;  it  happened,  that,  as  a  junior  officer  on  board 
his  ship,  he  had  been  placed  under  the  orders  of 
one  of  the  mates  when  the  captain  was  on  shore, 
and  for  some  trifling  offence  this  young  gentleman 
was  punished  in  the  following  manner:  —  His  foot 
was  placed  upon  a  small  projection  on  the  deck,  and 
his  arm  was  lashed  tightly  towards  the  yard  of  the 
ship,  and  thus  kept  extended  for  an  hour.  When 
he  returned  to  England,  he  had  the  power  of  rea- 
dily throwing  that  arm  from  its  socket,  merely  by 
raising  it  towards  his  head  ;  but  a  very  slight  ex- 
tension reduced  it ;  the  muscles  were  also  wasted, 
as  in  a  case  of  paralysis.    A  prosecution  was  com- 

three  inches  shorter  than  the  left^  which  on  inspection  was  found 
to  be  in  consequence  of  the  head  of  the  thigh  bone  having  slip- 
ped out  of  the  acetabulum,  and  of  this  he  could  give  no  account, 
unless  it  had  happened  when  on  board  of  ship,  whilst  changing 
from  hammock  to  hammock,  but  that  he  never  had  any  sense  of 
uneasiness  nor  pain^  either  then  or  at  any  other  time.' 

In  six  weeks,  by  the  aid  of  light  nourishing  diet  the  general 
health  of  the  patient  was  made  firm  and  hale,  though  the  dislo- 
cation upwards  still  continued.  He  took  Cinchona  during  a 
month  longer  and  the  dislocated  bone  was  entirely  restored  to 
its  place.  Had  the  ligaments  been  ruptured  the  bone  would 
have  remained  out,  but  as  the  condition  was  produced  by  the 
relaxed  state  of  the  ligaments  following  constitutional  debility, 
as  soon  as  the  strength  of  the  system  was  renewed,  the  liga- 
ments were  restored  to  their  natural  condition,  and  by  their  im- 
perceptible contraction  the  head  of  the  thigh-bone  was  return- 
ed to  the  socket.  J.  D.  G. 


36 


DISLOCATIONS  IN  GENERAL. 


nienced  for  this  act  of  cruelty,  and  I  was  subpoenaed 
to  give  evidence;  but  the  petty  tyrant  chose  to  pay 
the  forl'eit  of  his  misconduct  prior  to  the  commence- 
ment of  the  trial. 

I  have  also  seen  in  a  dislocation  of  the  thumb,  tlie 
first  phalanx  capable  of  being  thrown  from  the  os 
metacarpi  pollicis,  merely  by  the  action  of  the  mus- 
cles, from  a  relaxed  state  of  the  ligament. 

Of  the  influence  of  paralysis,  the  following  case  is 
an  example. 

Case,  —  I  was  desired  to  see  a  young  gentleman, 
who  had  one  of  those  paralytic  affections  in  his 
right  side  which  frequently  arise  during  dentition. 
The  muscles  of  the  shoulder  were  wasted  ;  and  he 
had  the  power  of  throwing  his  os  humeri  over  the 
posterior  edge  of  the  glenoid  cavity  of  the  scapula, 
from  whence  it  was  easily  to  be  reduced. 

In  these  cases,  particularly  in  the  latter,  no  lace- 
ration of  the  ligaments  could  have  occurred;  and 
they  show  the  influence  of  the  muscles  in  preventing 
dislocation  from  violence,  and  in  impeding  its  re- 
duction. 

Dislocation  from  ulceration,  —  Dislocations  arise 
from  ulceration,  by  which  the  ligaments  are  detach- 
ed, and  the  bones  become  altered  in  their  form.  We 
frequently  find  this  state  of  parts  in  the  hip-joint; 
the  ligaments  ulcerated,  the  edge  of  the  acetabulum 
absorbed,  the  head  of  the  thigh-bone  changed  both 
in  its  magnitude  and  figure,  escaping  from  the  ace- 
tabulum upon  the  ilium,  and  there  lorming  for  itself 
a  new  socket.  There  is  in  the  anatomical  collection 
at  St  Thomas's  Hospital,  a  pr'eparationof  the  knee 
dislocated  by  ulceration,  anchylosed  at  right  angles 
with  the  femur,  and  the  tibia  turned  directly  for- 
wards.   A  boy,  in  Guy's  Hospital,  had  his  knee  dis- 


DISLOCATIONS   IN  GENERAL. 


37 


located  by  ulceration,  with  the  tibia  thrown  on  the 
inner  side  of  the  external  condyle  of  the  os  ferno- 
ris;  and  a  girl,  in  the  same  hosjjital,  had  the  knee 
dislocated  by  ulceration,  the  head  of  the  tibia  being 
placed  behind  the  condyles  of  the  os  femoris.* 

Fracture  and  dislocation.  —  Dislocations  are  some- 
times accompanied  with  fracture.  At  the  ancle- 
joint,  it  rarely  happens  that  dislocation  occurs  with- 
out a  fracture  of  the  fibula;  and  at  the  hip-joint,  the 
acetabulum  is  occasionally  broken: — of  this  an  ex- 
ample will  be  seen  in  the  following  case. 

Case;  dislocation  ivith  organic  lesion.  —  Thomas 
Steers  was  admitted  into  Guy's  Hospital,  on  the  28th 
of  October,  1805,  with  a  dislocation  of  the  os  femo- 
ris  into  the  ischlatic  notch.  The  dislocation  was  re- 
duced by  a  very  slight  extension,  compared  with  that 
which  is  commonly  required:  this  was  imputed  to 
the  muscular  relaxation  caused  by  nausea,  the  patient 
having  vomited  at  the  time  of  his  admission. 
But  he  soon  complained  of  severe  pain,  extending 
over  his  abdomen,  and  he  died  on  the  day  following 
his  admission.  Upon  inspecting  his  body,  the  intes- 
tlnum  jejunum  was  found  ruptured;  and  upon  exam- 
ination of  the  hip-joint,  a  portion  of  the  edge  of  the 
acetabulum  was  discovered  to  be  broken  off. 

Dislocations  of  the  os  humeri  also  are  sometimes 
accompanied  with  fracture  of  the  head  of  that  bone; 
of  which  there  is  a  spocimen  in  the  Museum  of  St 
Thomas's  Hospital.    The  coronoid  process  is  occa-  - 

*  See  Mr  Brodie's  very  interesting  work  on  the  diseases  of  the 
joints.  Tiie  same  work  is  reprinted  in  volume  5tii,  of  the  Ec- 
lectic Repertory,  of  Philadelphia,  page  168.  J.  D.  G. 


38 


DISLOCATIONS   IN  GENERAL. 


sionally  broken  in  dislocations  of  the  ulna,  producing 
a  species  of  luxation,  which  does  not  permit  the  bone 
to  be  afterwards  preserved  in  its  natural  situation. 

Dislocation  and  fracture.  —  When  a  bone  is  both 
broken  and  dislocated,  it  is  proper  to  endeavour  to 
reduce  the  dislocation  without  loss  of  time,  taking 
care  that  the  fractured  part  be  strongly  bandaged  in 
splints,  to  prevent  any  injury  to  the  muscles;  for  if 
this  be  not  done  at  first,  it  cannot  be  afterwards  ef- 
fected without  danger  of  re-producing  the  fracture. 

If  a  compound  fracture  of  the  leg,  and  a  disloca- 
tion of  the  shoulder  happen  in  an  individual  at  the 
same  time,  the  reduction  of  the  arm  should  be  im- 
mediately undertaken,  after  the  fractured  limb  has 

been  secured  in  splints.     The  Rev.  Mr  H  , 

from  the  accident  of  being  thrown  from  his  chaise, 
had  a  compound  fracture  of  the  leg,  and  a  disloca- 
tion of  the  shoulder  forwards.  The  dislocation  was 
not  at  first  observed,  nor  was  its  reduction  attempted 
till  a  fortnight  had  elapsed.  The  trial  proved  un- 
successful, as,  from  a  dread  of  fever  and  injury  to  the 
leg,  sufficient  extension  could  not  be  used. 

The  accidents  which  have  been  called  dislocations 
of  the  spine,  are  generally  fractures  of  the  vertebrae, 
followed  by  displacement  of  the  bones,  but  not  of  the 
intervertebral  substance;  even  the  articulatory  pro- 
cesses are  broken,  as  well  as  the  bodies  of  the  ver- 
tebrae, so  that  they  are  not  triie  dislocations  of  the 
spine,  excepting  those  of  the  upper  cervical  verte- 
brae, dislocations  of  which  are  said  to  have  occasion- 
ally occurred.  The  injuries  of  the  spine,  which  pro- 
duce paralysis  of  the  lower  extremities,  arise  from 
fractured  portions  of  the  bodies  of  the  vertebrae, 
pressing  upon,  and  sometimes  lacerating  the  medulla 
spinalis. 

Compound  dislocations.  —  In  compound  dislocation^, 


DISLOCATIONS  IN  GENERAL. 


39 


not  only  the  articulatory  surfaces  of  the  bone  are 
displaced,  but  the  cavity  of  the  joint  is  laid  open  by 
a  division  of  the  skin  and  the  capsular  ligament. 
The  immediate  effect  of  compound  dislocation  is  to 
occasion  the  extravasation  of  blood  into  the  joint, 
and  to  allow  the  escape  of  the  synovia. 

Danger.  —  Compound  dislocations  are  attended 
with  great  danger,  and  for  the  following  reason:  — 
When  a  joint  is  opened,  inflammation  of  the  la- 
cerated ligaments  and  synovial  surface  speedily  suc- 
ceeds; in  a  few  hours  suppuration  begins,  and  granu- 
lations arise  from  the  surface  of  the  secreting  mem- 
brane;   which,  being  of  the  mucous  kind,  is  more 
disposed  to  the  suppurative,  than  to  the  adhesive 
inflammation.    But  tlie  same  process  does  not  im- 
mediately -ensue  upon  the  ex-trcmity  of  the  bone, 
because  it  is  covered   by  the   articular  cartilage. 
This  cartilage,  before  the  cavity  fills  with  granula- 
tions, becomes  absorbed,  by  an  ulcerative  process 
instituted  on  the  ends  of  the  bones,  but  sometimes 
beginning  from  the  synovial  surface.    The  bone  in- 
flames, the  cartilage  becomes  ulcerated,  numerous 
abscesses  are  formed  in  different  parts  of  the  joint, 
and  at  length  granulations  spring  from  the  extremi- 
ties of  the  bones  deprived  of  their  cartilages,  and 
fill  up  the  cavity;  generally  these  granulations  be- 
come ossified,  and  anchylosis  succeeds ;  but  some- 
times they  remain  of  a  softer  texture,  and  some  de- 
gree of  motion  in  the  joint  is  gradually  regained. 

This  process  of  filling  up  joints  requires  great 
general,  as  w^ell  as  local  efforts;  a  high  degree  of 
irritation  is  produced  ;  and  if  the  constitution  be 
weak,  the  patient,  to  preserve  his  life,  is  sometimes 
obliged  to  submit  to  amputation. 

Injury  to  muscles^  blood-vessels^  etc.  —  In  addition  to 
the  above  circumstances,  the  violence  necessarily  in- 
flicted on  the  parts,  in  compound  dislocations,  the  in- 


40 


DISLOCATIONS  IN  GENERAL. 


jury  of  the  muscles  and  tendons,  and  the  laceration 
of  blood-vessels,  necessarily  lead  to  more  important 
and  dangerous  consequences  than  those  which  follow 
simple  dislocations. 

Treatment, —  With  respect  to  the  treatment  of 
compound  dislocations,  I  propose  to  reserve  my  re- 
marks for  that  part  of  the  work  which  relates  to. 
injuries  of  the  ankle,  where  such  observations  will 
be  required,  and  whore  they  will  be  better  under- 
stood ;  and  thus  a  repetition,  superfluous,  and  per- 
haps irksome,  will  be  avoided.  I  shall  just  remark, 
that  some  joints  are  more  liable  to  compound  dis- 
locations than  others.  The  hip-joint  is  scarcely  ever 
so  dislocated ;  of  the  shoulder  I  have  known  two 
instances;  but  the  elbow,  wrist,  ankle,  and  fingers, 
are  frequently  the  seats  of  this  accident  ;  and  I  have 
seen  an  instance  of  it  at  the  knee. 

Some  joints  more  easily  dislocated  than  others.  —  In 
consequence  of  their  different  formation,  we  find 
that  in  some  joints,  dislocation  is  much  more  frequent 
than  in  others.  Those  which  have  naturally  exten- 
sive motions  are  easily  luxated,  and  hence  the  dislo- 
cation of  the  OS  humeri  occurs  much  more  frequent 
ly  than  that  of  any  other  bone;  and  having  once  oc- 
curred, it  happens  again  easily  in  the  mere  natural 
elevation  of  the  arm.  It  is  wisely  ordained,  that  in 
those  parts  to  which  extensive  motion  is  assigned, 
and  for  which  great  strength  is  required,  there  is  a 
multiplicity  of  joints.  Thus,  in  the  spine,  in  which 
great  strength  is  necessary  to  protect  the  spinal  mar- 
row, numerous  joints  are  formed,  and  the  motion 
between  any  two  of  the  bones  is  so  small,  that  dis- 
locations, except  between  the  first  and  second  verte- 
brae, rarely  occur,  although  the  bones  are  often  dis- 
placed by  fracture. 

The  carpus  and  the  tarsus  are  constituted  on  a 
similar  principle  ;  they  allow  of  considerable  motion, 


DISLOCATIONS  IN  GENERAL. 


41 


yet  maintain  great  strength  of  union.  For  if  the 
motion  between  two  bones,  as  in  the  spine,  be  mul- 
tiphed  by  twenty-four,  and  that  at  the  carpus  by 
eight,  the  result  will  show  that  great  latitude  of 
motion  is  given,  and  the  strength  of  the  part  pre- 
served ;  whilst,  if  the  spine  had  been  formed  of  a 
single  joint,  dislocations  might  have  easily  happened, 
and  death  from  this  cause  might  have  been  a  fre- 
quent consequence. 

Partial  dislocations,  —  Dislocations  are  not  always 
complete,  since  bones  are  sometimes  but  partially 
thrown  from  the  articulatory  surface  on  which  they 
rested ;  this  species  of  dislocation  now  and  then  oc- 
curs at  the  ankle-joint.  An  ankle,  afterwards  given 
to  the  Museum  at  St  Thomas's,  was  dissected  at 
Guy's  Hospital,  by  Mr  Tyrrell,  and  was  found  par- 
tially dislocated ;  the  end  of  the  tibia  still  rested  in 
part  upon  the  astragalus,  but  a  larger  portion  of  its 
surface  rested  on  the  os  naviculare ;  and  the  tibia, 
altered  by  this  change  of  place,  had  formed  two 
new  articulatory  surfaces,  with  their  faces  turned  in 
opposite  directions  towards  the  two  tarsal  bones. 
(See  Plate.)  The  dislocation  had  not  been  reduced. 
The  knee-joint  is,  I  believe,  rarely  dislocated  later- 
ally in  any  other  way;  for  its  extensive  articular  sur- 
faces almost  preclude  the  possibility  of  complete  dis- 
placement. The  OS  humeri  sometimes  rests  upon 
the  edge  of  the  glenoid  cavity,  and  readily  returns 
into  its  socket;  and  the  elbow-joint  is  dislocated  par- 
tially, both  in  relation  to  the  ulna  and  the  radius. 

The  lower  jaw  is  also  sometimes  partially  dislo- 
cated, but  in  a  different  manner;  one  of  the  joints 
being  luxated,  and  the  other  remaining  in  its  place. 

Cause,  —  Dislocations  are  generally  occasioned  by 
violence,  and  the  displacing  force  usually  takes  effect 
whilst  the  bone  is  in  an  oblique  direction  to  its  sock- 
et ;  but  the  muscles  must  necessarily  have  been  in  a 
6 


42 


DISLOCATIONS  IN  GENERAL. 


great  degree  unprepared  for  resistance,  otherwise 
the  greatest  force  would  hardly  have  produced  the 
effect:  when  they  are  unprepared,  the  injury  will 
often  ensue  from  very  slight  accidents.  A  fall,  in 
walking,  will  sometimes  dislocate  the  hip-joint,  when 
the  muscles  have  been  prepared  for  a  different  exer- 
tion. 

While  dwelling  on  this  subject  in  my  lectures,  I 
have  usually  adverted  to  the  execution  of,  Damien, 
as  illustrative  of  this  position. 

Resistance  of  muscles.  —  Damien  was  executed  for 
the  attempt  to  murder  Louis  XV.  Four  young 
horses  were  attached  to  his  legs  and  arms,  and  were 
forced  to  make  repeated  efforts,  to  tear  his  limbs 
from  his  body,  but  could  not  effect  this  purpose  ;  and 
after  fifty  minutes,  the  executioners  were  obliged  to 
cut  the  muscles  and  ligaments  to  effect  his  dismem- 
berment ;  or,  in  homelier  phrase,  to  hew  him  limb 
from  limb. 

The  following  is  the  French  account  of  this  exe- 
cution. 

'  II  arriva  a  la  place  de  Greve  a  trois  heures 
et  un  quart,  regardant  d'un  ceil  sec  et  ferme  le  lieuy 
et  les  instrumens  de  son  supplice.  On  lui  brula 
d'abord  la  main  droite ;  ensuite  on  le  tenailla,  et  on 
versa,  sur  ses  plaies,  de  I'huile,  du  plomb  fondu,  et 
de  la  poix-resine.  On  proceda  ensuite  a  I'ecartelle- 
ment.  Les  quatre  chevaux  firent  pendant  cinquante 
minutes  des  efforts  inutiles  pour  demembrer  ce 
monstre.  Au  bout  de  ce  terns  la,  Damien,  etant 
encore  plain  de  vie,  les  bourreaux  lui  couperent  avec 
de  bistouris,  les  chairs  et  les  jointures  nerveuses  des 
cuisses,  et  des  bras;  ce  qu'on  avoit  ete  oblige  de  faire 
en  1610  pour  Ravaillac.  II  respiroit  encore  apres 
que  les  cuisses  furent  coupees,  et  il  ne  rendit  I'ame 
que  pendant  qu'on  lui  coupoit  les  bras.  Son  supplice 
depuis  I'instant  qu'il  fut  mis  sur  I'echafaud,  jusqu'au 


DISLOCATIONS   IN  GENERAL. 


43 


moment  de  sa  mort,  dura  pres  d'une  heure  et  demie. 
II  conserva  toute  sa  connoissance,  et  releva  sa  tete 
sept  ou  huit  fois,  pour  regarder  les  chevaux,  et  ses 
membres  tenailles  et  brules.  Au  milieu  des  tourmens 
les  plus  affreux  de  la  question  il  avoit  laisse  echapper 
des  plaisanteries.'  —  Dictionnaire  Historique* 

Dislocations  rare  in  old  persons. —  Old  persons  are 
much  less  liable  to  dislocations  than  those  of  middle 
life,  because  the  extremities  of  bones  in  advanced 
age  are  often  so  soft  as  to  break  under  the  force 
applied,  rather  than  quit  their  natural  situations. 
Persons  of  lax  fibre  are  prone  to  dislocation,  because 
their  ligaments  easily  tear,  and  their  muscles  pos- 
sess little  power  of  resistance.  From  these  circum- 
stances old  people  would  be  exposed  to  frequent 
dislocations,  but  for  the  softened  state  of  the  ex- 
tremities of  their  bones. 

Dislocations  rare  in  the  young.  —  Young  persons 
are  also  very  rarely  the  subjects  of  dislocations  from 

*  At  a  quarter  after  three,  P.  M.,  Damien  arrived  at  the  place 
of  execution,  viewing  with  a  dry  and  steady  eye  the  situation 
and  instruments  of  his  punishment.  First  his  right  hand  was 
burned  ;  then  he  was  torn  with  pincers,  and  boiling  oil,  melted 
lead  and  pitch  were  poured  on  the  wounds.  The  separation  of 
the  body  ensued.  During  fifty  minutes,  the  four  horses  made 
useless  efforts  to  dismemljer  this  monster.  At  the  end  of  this 
time,  while  Damien  was  quite  alive,  the  executioners  cut  with 
knives  the  flesh  and  ligaments  of  the  thighs  and  arms,  as  they 
were  obliged  to  do  in  the  case  of  Ravaillac  in  16 JO.  He  breathed 
after  his  thighs  were  cut  and  did  not  expire  until  they  were  cut- 
ting his  arms.  His  execution  from  the  time  he  was  placed  on 
the  scaffold  till  the  moment  of  his  death,  lasted  nearly  an  hour 
and  a  half.  He  continued  perfectly  sensible,  and  raised  his  head 
seven  or  eight  times  to  look  at  the  horses  and  his  torn  and  burnt 
limbs.  In  the  midst  of  the  most  frightful  agonies  of  the  torture 
he  had  uttered  pleasantries. 

It  is  scarcely  possible  for  us  to  conceive  of  ^ monsters^  more 
horrid  than  the  executioners  and  spectators  capable  of  perpetrat- 
ing and  witnessing  such  a  punishment y"*  unless  we  think  of  the 
judges  by  whom  it  was  decreed.  J.  D.  G. 


44 


DISLOCATIONS  IN  GENERAL. 


violence  ;  but  now  and  then  such  accidents  do  occur; 
and  I  have  described  an  instance  of  them  in  a  child 
at  seven  years  of  age.  It  generally  happens  that 
their  bones  break,  or  their  epiphyses  give  way,  rath- 
er than  that  the  parts  suffer  displacement.  I  read 
of  dislocations  of  the  hip  in  children,  but  their  his- 
tory is  that  of  diseases  of  the  hip-joint,  in  which 
the  dislocation  has  arisen  from  ulceration.  A  child 
was  brought  to  me  from  one  of  the  counties  north 
of  London,  for  whom  repeated  extensions  had  been 
made  by  one  cf  those  people  called  hone-setters, — 
but  who  ought  rather  to  be  called  dtslocators, — 
for  a  supposed  dislocation  of  the  hip-joint.  Upon 
examination,  I  found  the  case  to  be  that  disease  of 
the  hip  which  is  so  common  in  children ;  and  for 
this  only,  was  a  child  wantonly  exposed  to  a  most 
painful  extension.  That  in  this  enlightened  country, 
men,  without  education,  should  be  suffered  with  im- 
punity to  degrade  a  most  useful  profession,  and  tor- 
ture those  who  have  the  folly,  or  the  simplicity  to 
apply  to  them,  is  a  disgrace  to  our  laws,  that  calls 
loudly  for  prevention. 

Elbow-joint  dislocations.  —  Dislocations  of  the  el- 
bow-joint in  children  are  said  to  be  of  frequent  oc- 
currence. Surgeons  have  been  heard  to  say,  '  I  have 
a  child  under  my  care  with  luxation  of  its  elbow, 
and  I  can  easily  return  the  bone  into  its  place,  but  it 
directly  dislocates  again.'  Such  a  case  is,  in  reality, 
an  oblique  fracture  of  the  condyles  of  the  os  hume- 
ri, which  produces  the  appearance  of  dislocation,  by 
allowing  the  radius  and  ulna,  or  the  ulna  alone,  to 
be  drawn  back  with  the  fractured  condyle,  so  as  to 
produce  considerable  projection  at  the  posterior  part 
of  the  joint. 


DISLOCATIONS  IN  GENERAL. 


45 


TREATMENT. 

Reduction^  8{c,  —  The  reduction  of  dislocations  is 
often  difficult ;  and  in  some  of  the  joints,  the  form 
of  the  bone  may  occasion  impediments.  Thus,  when 
the  socket  is  surrounded  by  a  lip  of  bone,  as  in  the 
hip-joint,  the  head  of  the  bone,  during  the  act  of 
reduction,  stops  at  this  projection,  and  requires  to 
be  lifted  over  it ;  another  difficulty  occurs  when  the 
head  of  the  bone  is  much  larger  than  its  cervix,  as 
for  example,  in  the  dislocation  of  the  head  of  the 
radius;  but  still  these  causes  are  slight  in  compari- 
son with  others  which  we  have  to  detail. 

Capsular  ligaments,  —  The  capsular  ligaments  are 
by  some  supposed  to  resist  reduction ;  but  those 
who  entertain  this'opinion  must  forget  their  inelas- 
tic structure,  and  cannot  have  had  opportunities  of 
witnessing  by  dissection,  the  extensive  laceration 
which  they  sustain  in  dislocations  from  violence. 
The  capsular  ligaments,  in  truth,  possess  but  little 
strength  either  to  prevent  dislocation,  or  to  resist 
the  means  of  reduction;  and  if  the  tendons  with 
which  they  are  covered,^and  the  peculiar  ligaments 
of  the  joints  did  not  exist,  dislocation  must  be  of 
very  frequent  occurrence. 

Tendons  ;  peculiar  ligaments,  —  The  joint  of  the 
shoulder,  and  those  of  the  knee  and  elbow,  are 
strongly  protected  by  tendons  ;  the  shoulder  by  those 
of  the  spinati,  sub-scapularis  and  teres-minor  mus- 
cles ;  the  elbow  by  the  triceps  and  brachialis  ;  the 
knee  by  the  tendinous  expansion  of  the  vasti :  but 
still  some  ligaments  resist  dislocations  ;  these,  how- 
ever, are  the  peculiar,  not  the  capsular  ligaments. 
The  wrist  and  the  elbow  have  their  appropriate 
lateral  ligaments  to  give  additional  strength  to  these 
joints.    The  shoulder,  instead  of  a  peculiar  ligament, 


46 


DISLOCATIONS  IN  GENERAL. 


has  the  tendon  of  the  biceps  received  into  it,  which 
lessens  the  tendency  to  dislocation  forwards ;  the 
ligamentum  teres  of  the  hip-joint  prevents  facihtjof 
dislocation  downwards ;  the  knee  has  its  lateral  and 
crucial  ligaments;  and  the  ankle,  exposed  as  it  is  to 
the  most  severe  injuries,  is  provided  with  its  deltoid 
and  fibular  tarsal  ligaments,  of  very  extraordinary 
strength,  to  prevent  dislocation.  The  bones  of  this 
joint  often  break  rather  than  their  ligaments  give 
way;  however,  in  many  of  the  joints,  as  these  liga- 
ments are  torn,  they  afford  no  resistance  to  the  re- 
duction of  dislocations,  as  in  the  hip,  elbow,  and 
wrist;  but  if  one  of  them  remain,  it  produces  dif- 
ficulty in  the  reduction,  as  I  have  seen  in  the  knee- 
joint. 

Muscles.  —  The  difficulty  in  reducing  dislocations 
arises  principally  from  the  resistance  which  the  mus- 
cles present  by  their  contraction,  and  which  is  pro- 
portioned to  the  length  of  time  which  has  elapsed 
from  the  injury;  it  is  therefore  desirable  that  the 
attempt  at  reduction  should  not  be  long  delayed. 

The  common  actions  of  the  muscles  are  volun- 
tary or  involuntary,  but  they  have  a  power  of  con- 
traction independent  of  either  state. 

Fatigue  of  muscles.  —  A  muscle,  when  excited  to 
action  by  volition,  soon  becomes  fatigued,  and  re- 
quires rest.  The  arm  can  be  extended  only  for  a 
few  minutes,  at  right  angles  with  the  body,  before 
it  feels  a  fatigue  which  requires  a  suspension  of  ac- 
tion ;  and,  indeed,  the  same  law  governs  involuntary 
action,  as  the  heart  has  its  contraction  and  relaxation. 

Permanent  contraction.  —  But  when  a  muscle  is 
divided,  its  parts  contract;  or  when  the  antagonist 
muscle  is  cut,  the  undivided  muscle  draws  the  parts 
into  which  it  is  inserted,  into  a  fixed  situation.  Thus, 
if  the  biceps  muscle  be  divided,  the  triceps  keeps 
the  arm  constantly  extended  ;  if  the  muscles  on  one 


DISLOCATIONS  IN  GENERAL. 


47 


side  of  the  face  be  paralytic,  the  opposing  muscles 
draw  the  face  to  their  side.  This  contraction  is 
not  succeeded  by  fatigue  or  relaxation,  but  will  con- 
tinue an  indefinite  time,  even  until  the  structure  of 
the  muscle  becomes  changed ;  and  its  contraction 
increases  from  the  first  occurrence  of  the  accident. 
Thus  it  is,  that  when  a  bone  is  dislocated,  the  mus- 
cles draw  it  as  far  from  the  joint  as  the  surrounding 
parts  will  allow,  and  there  retain  it  by  their  con- 
traction.  It  is  this  resistance  from  muscles,  aided 
by  their  spontaneous  contraction,  which  the  surgeon 
is  required  to  counteract,  [f  an  extension  be  made 
almost  immediately  after  a  dislocation  has  happen- 
ed, the  resistance  produced  by  the  muscles  is  easily 
overcome  :  but  if  the  operation  be  postponed  for  a 
few  days  only,  the  utmust  difficulty  occurs  in  its  ac- 
complishment. 

Vis  tonica  of  muscles.  —  Mr  Forster,  son  of  the 
surgeon  of  Guy's  Hospital,  informed  me,  that  in  a 
fatal  case  of  fracture  of  the  thigh-bone,  which  be 
had  an  opportunity  of  dissecting  before  its  union^ 
the  ends  of  the  bones  overlapped,  and  the  muscles 
had  acquired  a  contraction  so  rigid,  that  he  could  not, 
even  in  the  dead  body,  bring  the  bones  to  their  nat- 
ural position,  after  employing  all  the  force  he  was 
capable  of  exerting.  It  is  this  state  of  muscles  in 
dislocations,  which  gives  rise  to  the  difficulty  in  their 
reduction,  and  which,  even  in  the  dead  body,  is  still 
capable  of  opposing  a  very  considerable  resistance.* 

*  We  must  remember,  under  such  circumstances,  that  the 
nature  of  the  fibre  has  been  very  materially  altered,  and  instead 
of  true  muscular  texture  has  become  a  dense  fibrous  matter  more 
resembling  ligament  than  any  other  substance.  Corresponding 
to  this  alteration  is  the  change  subsequently  mentioned,  where 
the  socket  for  the  bone  is  not  only  filled  up  by  the  deposition  of 
'  adhesive  matter,'  but  the  proper  figure  of  the  socket  is  de- 
stroyed by  absorption  of  the  bony  edges.  J.  D.  G. 


48 


DISLOCATIONS  IN  GENERAL. 


That  the  muscles  are  the  chief  cause  of  resistance, 
is  strongly  evinced  by  those  cases  in  which  the  dislo- 
cation is  accompanied  by  injury  to  any  vital  organ, 
and  when  the  power  of  muscular  action  is  diminish- 
ed; for  it  is  then  found,  that  a  very  slight  force  is 
sufficient  to  return  the  bone  to  its  situation.  Thus, 
in  the  case  already  mentioned,  of  the  man  who  had 
an  injury  to  his  jejunum,  and  a  dislocation  of  his  hip, 
the  bone  was  restored  to  its  place  with  little  diffi- 
culty. 

Other  difficulties,  —  When  a  dislocation  has  long 
existed,  difficulties  arise  from  three  other  circum- 
stances. The  extremity  of  the  bone  contracts  adhe- 
sion to  the  surrounding  parts,  so  that  even  when  in 
dissection  the  muscles  are  removed,  the  bone  cannot 
be  reduced.  In  this  state  I  found  the  head  of  a 
radius,  which  had  been  long  dislocated,  resting  upon 
the  external  condyle  of  the  os  humeri,  and  which  is 
preserved  in  the  collection  at  St  Thomas's  Hospital 
(see  plate)  ;  and  in  a  similar  state  1  have  seen  the  os 
humeri  when  dislocated.  The  socket  is  also  some- 
times so  filled  with  adhesive  matter,  that  if  the  bone 
were  reduced,  it  could  not  remain  in  its  original  sit- 
uation, and  the  original  cavity  is  in  part  filled  with 
ossific  matter,  so  as  to  render  it  incapable  of  receiv- 
ing the  head  of  the  bone.  Lastly:  a  new  bony 
socket  is  sometimes  formed,  in  which  the  head  of  the 
bone  is  so  completely  confined,  that  nothing  but  its 
fracture  will  allow  it  to  escape  from  its  new  situation. 
(See  plate.) 

Means  of  reduction.  —  The  means  to  be  employed 
for  the  reduction  of  dislocations,  are  both  constitu- 
tional and  mechanical ;  force  alone  is  in  general  ob- 
jectionable, since  it  would  be  required  in  so  great  a 
degree  as  to  occasion  violence  and  injury  ;  and  it  will 
in  the  sequel  be  shown,  that  the  most  powerful  me- 
chanical means  fail  when  unaided  by  constitutional 


DISLOCATIONS  IN  GENERAL. 


49 


remedies.  The  power  and  direction  of  the  larger 
muscles  are,  in  the  first  instance,  to  be  duly  appre- 
ciated, as  these  form  the  principal  causes  of  resist- 
ance. 

Constitution  ah  —  The  constitutional  expedients  ap- 
plicable for  the  purpose  of  reduction  are  those 
which  produce  a  tendency  to  syncope,  and  this  ne- 
cessary state  may  be  best  induced  by  one  or  other 
of  the  following  means,  viz :  bleeding,  warm-bath 
and  nausea.  Of  these  remedies,  I  consider  bleeding 
the  most  powerful ;  and,  that  the  effect  may  be  pro- 
duced as  quickly  as  pos^^ible,  the  blood  should  be 
drawn  from  a  large  orifice,  and  the  patient  kept  in 
the  erect  position,  for  by  this  mode  oi  depletion, 
syncope  is  produced  before  too  large  a  quantity  of 
blood  is  lost.  .  However,  the  activity  of  this  practice 
must  be  regulated  by  the  constitution  of  the  patient; 
if  he  be  young,  athletic,  and  muscular,  the  quantity 
removed  should  be  considerable,  and  the  method  of 
taking  it  away  should  be  that  which  1  have  de- 
scribed. 

Secondly;  in  those  cases  in  which  the  warm-bath 
may  be  thought  preferable,  or  where  it  may  be  con- 
sidered improper  to  continue  the  bleeding,  the  bath 
should  be  employed  at  the  temperature  of  J00°  to 
110°;  and,  and  as  the  object  is  the  same  as  in  bleed- 
ing, the  person  should  be  kept  in  the  bath  at  the 
same  heat  till  the  fainting  effect  is  produced,  when 
he  should  be  immediately  placed  in  a  chair,  wrapped 
in  a  blanket,  and  the  mechanical  means  employed 
which  I  shall  hereafter  particularly  describe. 

Of  late  years,  I  have  practised  a  third  mode  of 
lowering  the  action  of  the  musclqs,  by  exhibiting 
nauseating  doses  of  tartarized  antimony;  but  as  its  # 
action  is  uncertain,  frequently  producing  vomiting, 
which  is  unnecessary,  I  rather  recommend  its  appli- 
cation merely  to  such  extent  as  to  keep  up  the  state 
7 


50 


DISLOCATIONS  IN  GENERAL. 


of  syncope  already  produced  by  the  two  preceding 
means  ;  this  its  nauseating  tendency  will  most  readily 
effect,  and  so  powerfully  overcome  the  tone  of  the 
muscles,  that  dislocations  may  be  reduced  with  much 
less  effort,  and  at  a  much  more  distant  period  from 
the  accident,  by  the&e  means,  than  in  any  other  way.* 
The  two  cases  related  in  the  following  pages,  one 
from  Mr  Norwood,  surgeon,  at  Hertford,  and  the 
other  from  Mr  Thomas,  apothecary  to  St  Luke's 
Hospital,  will  illustrate  the  efficacy  of  the  treatment 
recommended.  By  the  combination  of  bleeding,  the 
warm-bath,  and  nauseatin§^-doses  of  tartarised  anti- 
mony, two  dislocations  w^ere  reduced  at  a  more  dis- 
tant period  from  the  accident  than  I  have  ever 
known  in  any  other  example.  One  of  these  cases 
occurred  at  Guy's,  and  the  other  at  St  Thomas's 
Hospital,  at  the  time  when  these  gentlemen  were 
officiating  as  dressers.  (^See  cases  of  dislocation  on  the 
ilium.) 

Opium.  —  The  effect  of  opium  I  have  never  tried, 
but  it  would  probably  be  useful  in  a  large  dose,  from 
its  power  of  diminishing  muscular  and  nervous  in- 
fluence.t 

Mechanical  means.  —  The  reduction  of  the  bone 
is  to  be  attempted,  after  lessening  the  power  of  the 
muscles,  by  fixing  one  bone,  and  drawing  the  other 
towards  its  socket.  It  is  now  generally  agreed 
among  the  most  eminent  surgeons,  that  force  should 

*  Mr  Burford  Wilmer  proposed  the  use  of  tartar  emetic  in  the 
following  manner,  in  the  London  Medical  and  Physical  Journal 
for  10 10.  Having  every  thing  in  readiness  to  effect  the  reduction, 
the  medicine  was  administered,  and  as  soon  as  the  nausea  and 
faintness  were  fairly  evident,  the  reduction  was  begun,  and  fin- 
ished with  comparative  ease  while  this  state  continued. 

J.  D.  a 

t  The  administration  of  spirits  until  full  intoxication  was  pro- 
duced, has  several  times  been  resorted  to  in  this  country.  T?he 
practice  cannot  be  generally  recommended.  J.  D.  G. 


DISLOCATIONS   IN  GENERAL. 


51 


be  only  gradually  applied  ;  for  violence  is  as  likely 
to  tear  sound  parts,  as  to  reduce  those  which  are 
luxated;  and  it  is  apt  to  excite  all  the  powers  of 
resistance  to  oppose  the  efforts  of  the  surgeon. 
Hence  it  becomes  his  duty  to  produce,  gradually, 
that  state  of  fatigue  and  relaxation  which  is  sure  to 
follow  continued  extension,  and  not  to  attempt  at 
once  to  overpower  the  action  of  the  muscles. 

One  great  cause  of  failure  in  the  attempt  to  re- 
duce dislocations,  ai'ises  from  insufficient  attention  to 
the  fixation  of  that  bone  in  which  the  socket  is  plac- 
ed. For  example:  in  attempting  to  reduce  a  dis- 
location of  the  shoulder,  if  the  scapula  be  not  fixed, 
or  if  one  person  pull  at  the  scapula  and  two  at  the 
arm,  the  scapula  will  be  necessarily  drawn  with  the 
OS  humeri,  and  the  extension  will  be  very  imperfectly 
made;  the  one  bone,  therefore,  must  be  firmly  fixed, 
or  drawn  in  the  opposite  direction,  while  the  other 
is  extended. 

Compound  'pulley.  —  The  force  required  may  be 
applied  either  by  the  exertion  of  assistants,  or  by  a 
compound  pulley;  but  the  object  is  to  extend  the 
muscles  by  gradual,  regular,  and  continued  efforts; 
in  cases  of  difficulty  recourse  should  always  be  had 
to  the  pulley;  its  effect  may  be  gentle,  continued, 
and  directed  by  the  surgeon's  mind;  but  when  assist- 
ants are  employed,  their  exertions  are  sudden,  vio- 
lent, and  often  ill  directed ;  and  the  force  is  more 
likely  to  produce  laceration  of  parts,  than  to  restore 
the  bone  to  its  situation.  Their  effiarts  are  also  fre- 
quently uncomblned,  and  their  muscles  as  necessarily 
become  fatigued  as  those  of  the  patient,  whose  resist- 
ance they  are  employed  to  subdue. 

In  dislocation  of  the  hip-joint,  pulleys  should  al- 
ways be  employed;  and  in  those  dislocations  of  the 
shoulder  which  have  long  remained  unreduced,  they 
should  also  be  resorted  to.    I  do  not  mean  to  doubt 


OF  ILL  IJO. 


52 


DISLOCATIONS   IN  GENERAL. 


the  possibility  of  reducing  dislocations  of  the  hip  by 
the  aid  of  men  only,  but  to  point  out  the  inferiority 
of  this  mode  to  the  mechanical  means.  The  em- 
ployment of  pulleys  in  dislocations,  is  not  a  modern 
practice  :  Ambrose  Pare  frequently  had  recourse  to 
them,  and  good  practical  surgeons  have  used  them 
since  his  time; — most  writers  on  surgery  have  also 
mentioned  their  use,  but  they  have  not  duly  appre- 
ciated them.  Mr  Cline,  whose  professional  judgment 
every  one  must  acknowledge,  always  strongly  re- 
commended them. 

Relaxation  of  the  stronger  muscles.  —  During  the 
attempt  to  reduce  luxations,  the  surgeon  should 
endeavour  to  obtain  a  relaxation  of  the  stronger 
opposing  muscles.  The  limb  should  therefore  be 
kept  in  a  position  between  flexion  and  extension,  as 
nearly  as  that  medium  can  be  obtained.  Who  has 
not  seen,  in  the  attempt  to  reduce  a  compound  frac- 
ture in  the  extended  position  of  a  limb,  the  bone, 
whicti  could  not  be  brought  into  apposition  under 
the  most  violent  efforts,  quickly  replaced  by  an  intel- 
ligent surgeor),  who  has  directed  the  limb  to  be  bent, 
and  the  muscles  to  be  placed  in  a  comparative  state 
of  relaxation? 

Whether  the  extension  should  he  applied  to  the  dis- 
located bone.  —  A  difference  of  opinion  prevails, 
whether  it  is  best  to  apply  the  extension  on  the 
dislocated  bone,  or  on  the  limb  below.  M.  Boyer, 
who  has  long  taken  the  lead  in  surgery  in  Paris, 
prefers  the  latter  mode.  As  far  as  I  have  had  an 
opportunity  of  observing,  it  is  generally  best  to 
apply  the  extension  to  the  bone  which  is  dislocated. 
There  are,  however,  exceptions  to  this  rule  in  the 
dislocation  of  the  shoulder,  which  I  generally  re- 
duce by  placing  the  heel  in  the  axilla,  and  by  draw- 
ing the  arm  at  the  wrist  in  a  line  with  the  side  of 
the  body. 


DISLOCATIONS   IN  GENERAL.* 


53 


Influence  of  the  mind.  —  In  the  reduction  of  dislo- 
cations, great  advantage  is  derived  from  attending 
to  the  patient's  mind  ;  the  muscles  opposing  the  ef- 
forts of  the  surgeon,  by  acting  in  obedience  to  the 
will,  may  be  made  to  desist  from  that  action  by  di- 
recting the  mind  to  other  muscles.  Several  years 
since,  a  surgeon  in  Blackfriars'  Road,  asked  me  to 
see  a  patient  of  his  with  a  dislocated  shoulder,  wliich 
had  resisted  the  various  attempts  he  had  made  at  re- 
duction. I  found  the  patient  in  bed, with  his  right  arm 
dislocated;  I  sat  down  on  the  bed  by  his  side,  placed 
my  heel  in  the  axilla,  and  drew  the  arm  at  the  wrist; 
the  dislocated  bone  remained  unmoved,  I  said,  '  Rise 
from  your  bed.  Sir;'  he  made  an  effort  to  do  so, 
whilst  I  continued  my  extension,  and  the  bone  snap- 
ped into  its  socket.  For  a  siniilar  reason,  a  slight 
effort,  when  the  muscles  are  unprepared,  will  accom- 
plish the  reduction  of  dislocation,  after  violent  mea- 
sures have  failed. 

The  reduction  of  the  limb  is  ascertained  by  the 
restoration  of  its  natural  form,  by  the  recovery  of 
its  original  motion,  and  by  a  snap,  or  sudden  sound 
which  is  heard  when  the  bone  returns  into  its  arti- 
culatory  cavity. 

Second  dislocation.  —  After  a  bone  has  been  re- 
duced by  the  pulleys,  it  will  not  remain  in  its  situa- 
tion without  the  aid  of  bandages  to  support  it  until 
the  recovery  of  muscular  action.  In  the  hip,  how- 
ever, dislocation  rarely  occurs  a  second  time,  but  the 
shoulder  and  the  lower  jaw  very  frequently  slip 
again  from  their  sockets,  owing  to  the  little  depth  of 
the  cavity  into  which  the  head  of  the  bone  is  re- 
ceived ;  and,  therefore,  they  require  bandages  for  a 
considerable  period. 

Rest  of  the  limb. — Rest  is  necessary  for  some 
time  after  the  reduction  of  the  limb,  in  order  to  pro- 
duce an  union  of  the  ruptured  ligament,  which 


04 


i)ISLOCATIONS    IN  GENERAL. 


would  be  prevented  by  exercise.  The  strength  of 
the  muscles  and  ligaments  may  also  be  greatly  pro- 
moted by  effusion  of  cold  water  upon  the  limb,  and 
by  subsequent  friction. 

Old  dislocations  not  to  be  reduced. — -I  believe  that 
much  mischief  is  produced  by  attempts  to  reduce 
dislocations  of  long  duration  in  very  muscular  per- 
sons. I  have  seen  great  contusion  of  the  integu- 
ments, laceration  and  bruises  of  muscles,  tension  of 
nerves,  inducing  an  insensibility  and  paralysis  of  the 
hand,  occasioned  by  an  abortive  attempt  to  reduce  a 
dislocation  of  the  shoulder  j  so  that  the  patient's 
condition  has  been  rendered  much  worse  than  be- 
fore. In  such  cases,  even  when  the  bone  is  replaced, 
it  has  often  proved  rather  an  evil  than  a  benefity 
from  the  violence  of  the  extension. 

In  those  instances  in  which  the  bone  remains  in 
the  axilla,  in  dislocations  of  the  shoulder,  a  service- 
able limb,  and  very  extensive  motions  of  it  may  be 
regained,  although  reduction  has  not  been  effected. 
Captain  S- — — ,  who  had  dislocated  his  shoulder 
four  years  before,  called  to  show  me  how  much  mo- 
tion he  had  recovered,  although  the  arm  still  re- 
mained unreduced. 

Time  for  attempting  reduction.  —  I  am  of  opinion, 
that  three  months  after  the  accident  for  the  shoul- 
der, and  eight  weeks  for  the  hip,  may  be  fixed  as 
the  period  at  which  it  would  be  imprudent  to  make 
the  attempt  at  reduction,  except  in  persons  of  ex- 
tremely relaxed  fibre,  or  of  advanced  age.  At  the 
same  time,  I  am  fully  aware,  that  the  shoulder  has 
been  reduced  at  a  more  distant  period  than  that  which 
I  have  mentioned;  but,  in  most  instances,  the  reduc- 
tion has  been  attended  with  the  results  I  have  just 
been  deprecating. 

In  cases  of  unreduced  dislocation,  the  only  course 
which  the  surgeon  can  adopt,  after  the  inflammation 


DISLOCATIONS    IN  GENERAL. 


5.0 


which  the  injury  produces  has  subsided,  is,  to  advise 
motion  of  the  limb,  and  friction  of  the  injured  part; 
—  The  former,  to  produce  a  new  cavity  for  the 
head  of  the  bone,  to  assist  in  forming  a  new  liga- 
ment, and  to  restore  action  to  muscles,  which  they 
would  otherwise  lose  by  repose  the  latter,  to  pro- 
mote absorption,  and  remove  the  swelling  and  ad- 
hesions which  the  accident  has  caused. 


PARTICULAR  DISLOCATIONS. 


DISLOCATIONS    OF  THE  HIP-JOINT. 

Jlnatomy  of  the  joint. —  The  acetabulum  of  the 
hip-joint  is  deepened  by  a  cartilaginous  ridge,  which 
surrounds  its  brim;  and  although  in  the  skeleton  it 
is  not  a  complete  cup,  yet  it  is  rendered  such  in  the 
living  subject,  by  an  additional  portion  of  cartilage, 
which  fills  up  a  depression  in  the  bone  in  the  infe-* 
rior  and  anterior  part  of  the  cavity. 

Ligaments,  —  The  ligaments  are  two  :  the  capsu- 
lar arises  from  the  edge  of  the  acetabulum,  and 
passing  over  the  head  and  neck  of  the  bone,  is  in- 
serted into  the  cervix  of  the  os  femoris  at  the  root 
of  the  trochanter  major.  It  is  much  more  exten- 
sive on  the  anterior  than  on  the  posterior  portion  of 
the  neck  of  the  bone.  The  inner  side  of  this  liga- 
ment is  a  secreting  surface,  producing  the  synovia  ; 
and  a  reflected  portion  of  it  towards  the  head  of 
the  bone  is  also  provided  with  a  similar  secreting 
surface."^ 

It  has  been  universally  understood  hitherto,  that  the  capsu- 
lar ligaments  of  the  joints  are  peculiar,  or  independent  struc- 
tures. During  the  last  winter  I  was  led  hy  a  number  of  careful 
researches  to  discover  that  the  capsular  ligaments  of  the  great 
joints  are  formed  from,  the  fascia  covering  the  muscles.  The 
great  capsule  of  the  hip-joint  is  made  up  by  the  different  lay- 
ers of  the  Fascia  Lata,  and  the  capsule  of  the  shoulder  joint  is 


PARTICULAR  DISLOCATIONS. 


57 


On  the  anterior  surface  of  the  neck  of  the  thigh- 
bone, the  capsular  h'gament  is  received  into  a  line, 
which  extends  from  the  trochanter  major  to  the 
trochanter  minor.  The  synovial  secreting  surface 
is  reflected  towards  the  head  of  the  bone,  and  the 
ligament  is  reflected  close  on  the  neck  of  the  bone, 
to  form  the  periosteum;  whilst  its  fibres  are  inter- 
serted  with  the  common  periosteum,  below  the  in- 
sertion of  the  ligament,  into  the  bone. 

On  the  posterior  surface  the  capsular  ligament  is 
received  upon  the  neck  of  ilie  bone,  nearly  midway 
between  the  edge  of  the  head  of  the  bone  and  the 
trochanter  major.  The  common  periosteum  on  the 
neck  of  the  bone  incorporates  with  the  reflected 
ligament,  to  form  the  periosteum  of  the  neck  of  the 
bone  within  the  capsule.* 

The  ligamentum  teres  is  contained  within  the  cap- 
sular ligament,  and  proceeds  from  a  depression  in 
the  lower  and  inner  part  of  the  acetabulum,  to  be 
fixed  in  a  hollow  upon  the  inner  side  of  the  thigh- 
bone :  it  has  a  tendency  to  prevent  dislocations  in 
all  directions, 'but  particularly  the  dislocation  down- 
wards;  for  when  this  dislocation  occurs,  the  thighs 
are  widely  separated  from  each  other,  as  in  fencing; 

a  simple  continuation  of  the  fascia  covering  the  biceps  flexor 
cubiti,  which  1  have  called  '  Fascia  Hunieri.'  When  the  inter- 
esting manner  in  which  these  faciae  surround  the  muscles  and 
form  the  sheaths  for  the  vessels,  is  understood,  the  important 
bearing  these  facts  must  have  on  the  physiology  and  pathology 
of  the  joints,  will  be  clearly  perceived.  For  a  full  description 
of  the  relations  existing  between  these  parts,  1  must  refer  the 
reader  to  the  '  Anatomical  Investigations'  recently  published. 

J.  D.  G. 

*  Query.  —  Can  this  ligamentous  periosteum  be  one  cause  of 
a  ligamentous  union  in  fractures  within  the  joints?  I  believe 
that  when  an  union  of  the  neck  of  the  thigh-bone  is  met  with, 
it  must  be  in  a  case  in  which  this  Hgamentous  sheath  of  the 
cervix  has  not  been  torn.  {See  Plate  XIII,  Jig.  3.) 
B 


58 


PARTICULAR  DISLOCATIONS. 


and  the  head  of  the  thigh-bone  would  be  in  danger 
of  slipping  from  its  socket,  were  it  not  prevented  by 
this  ligament — an  example  of  its  use,  which  shows 
the  principal  reason  of  its  formation.* 

Mode  of  dislocation. — The  thigh-bone  I  have 
seen  dislocated  in  four  directions  :  —  First,  upwai'ds, 
or  upon  the  dorsum  of  the  ilium.  Secondly,  down- 
wards, or  into  the  foramen  ovale.  Thirdly,  back- 
wards, and  upwards,  or  into  the  ischiatic  notch  ;  and, 
Fourthly,  forwards,  and  upwards,  or  upon  the  body 
of  the  pubes.  A  dislocation  downwards  and  back- 
wards, has  been  described  by  some  surgeons,  who 
have  had  opportunities  for  observation  ;  but  I  have 
to  remark,  that  no  dislocation  of  that  description 
has  occurred  at  St  Thomas's  or  Guy's  Hospital, 
within  the  last  thirty  years,  or  in  my  private  prac- 
tice ;  and  although  1  w-ould  not  deny  the  possibility 
of  its  occurrence,  yet  I  am  disposed  to  believe  that 
some  mistake  has  arisen  upon  this  subject. 


DISLOCATION  UPWARDS,  OR  ON  THE  DORSUM  ILIl. 

Dislocation  on  the  dorsum  ilii,  —  This  dislocation 
is  the  most  frequent  of  those  which  happen  to  the 
hip-joint:  and  the  following  are  the  signs  of  its  ex- 
istence. 

Symptoms,  —  The  dislocated  limb,  is  from  one 
inch  and  a  half,  to  two  inches  and  a  half  shorter  than 
the  other,  as  will  be  seen  by  comparing  the  malleoli 

*  The  ligntnentnm  teres  does  not  arise  from  the  depression 
at  the  bottom  of  the  acetabuhim,  nor  are  the  connexions  at  this 
point  very  strong.  The  round  ligament  really  arises  from  that 
ligament  which  completes  the  circle  of  the  acetabulum  at  the 
anterior  [»art.  This  interesting  and  easily  demonstrable  fact, 
appears  to  have  been  first  remarked  by  our  celebrated  country- 
man, the  late  professor  Wislar.  J.  D.  G. 


PARTICULAR  DISLOCATIONS. 


59 


interni,  when  the  foot  is  bent  at  right  angles  with 
the  leg.  The  toe  rests  upon  the  tarsus  of  the  other 
foot;  the  knee  and  foot  are  turned  inwards,  and  the 
knee  is  a  little  advanced  upon  the  other.  When 
the  attempt  is  made  to  separate  the  leg  from  the 
other,  it  cannot  be  accomplished,  for  the  limb  is 
firmly  fixed  in  its  new  situation,  so  far  as  regards  its 
motion  outwards;  but  the  thigh  can  be  slightly  bent 
across  the  other.  If  the  bone  be  not  concealed  by 
extravasation  of  blood,  the  head  of  the  thigh-bone 
can  be  perceived  during  rotation  of  the  knee  inwards, 
moving  upon  the  dorsum  ilii;  and  the  trochanter 
major  advances  towards  its  anterior  and  superior 
spinous  process,  so  as  to  be  felt  much  nearer  to  it 
than  usual.  The  trochanter  is  less  prominent  than 
on  the  opposite  side,  for  the  neck  of  the  bone  and 
the  trochanter  rest  in  the  line  of  the  surface  of  the 
dorsum  ilii;  and  upon  a  comparison  of  the  two  hips, 
the  roundness  of  the  dislocated  side  will  be  found  to 
have  disappeared.  A  surgeon,  then,  called  to  a 
severe  and  recent  injury  of  the  hip-joint,  looks  for 
difference  in  length,  change  of  position  inwards,  dim- 
inution of  motion,  and  decreased  projection  of  the 
trochanter. 

Distinction  from  fracture  of  the  neck  of  the  femur, 
—  The  accident  with  which  the  dislocation  upwards 
is  liable  to  be  confounded,  is  the  fracture  of  the  neck 
of  the  thigh-bone  within  the  capsular  ligament.  Yet 
the  marks  of  distinction  are,  in  general,  sufficiently 
strong  to  be  unequivocal  to  a  person  commonly  at- 
tentive. In  a  fracture  of  the  neck  of  the  thigh-bone, 
the  knee  and  foot  are  generally  turned  outwards; 
the  trochanter  is  drawn  upwards  and  backwards, 
resting  upon  the  dorsum  ilii;  the  thigh  can  he  readily 
bent  towards  the  abdomen,  although  with  some  pain; 
but,  above  all,  the  limb,  which  is  shortened  according 
to  the  duration  of  the  accident,  from  one  to  two 


60 


PARTICULAR  DISLOCATIONS. 


inches,  bj  the  contraction  of  the  muscles,  can  be 
made  of  the  length  of  the  other'  by  a  slight  exten- 
sion; and  when  the  extension  is  abandoned,  the  leg 
is  again  shortened.  If  the  limb,  when  drawn  down 
be  rotated,  a  crepitus  can  often  be  felt,  which  ceases 
to  be  perceived  when  rotation  is  performed  under  a 
shortened  state  of  the  limb.  Fracture  of  the  neck 
of  the  thigh-bone,  within  the  capsular  ligament,  rarely 
occurs  but  in  advanced  age;  and  tlie  most  trifling  ac- 
cident is  sufficient  to  produce  it,  in  consequence  of 
the  interstitial  absorption  which  this  part  of  the  bone 
undergoes  at  advanced  periods  of  life.  Fractures 
.externally  to  the  capsular  ligament,  occur  at  any  age, 
and  they  are  easily  distinguished  by  the  crepitus 
which  attends  them,  if  the  limb  be  rotated  and  the 
trochanter  compressed  with  the  hand.  The  position 
is  the  same  as  in  fractures  within  the  ligament. 
Fractures  of  the  neck  of  the  thigh-bone  are  very 
frequent  accidents  when  compared  with  dislocations. 
(^See  the  plate  of  the  positions  of  the  limh  in  disloca- 
tions,) 

Disease  of  the  hip-joint,  —  Diseases  of  the  hip-joint 
can  scarcely  ever  be  confounded  with  dislocations 
from  violence,  but  by  those  who  are  ignorant  of 
anatomy,  and  who  are  very  superficial  observers. 
The  gradual  progress  of  the  symptoms,  the  pain  in 
the  knee,  with  the  apparent  elongation  at  first,  and 
real  shortening  afterw^ards;  the  capacity  for  motion, 
yet  the  pain  given  under  extremes  of  rotation,  as 
well  as  of  flexion  and  extension,  are  indications  of 
difference  which  would  strike  the  most  careless  ob- 
server. The  consequences  of  a  disease  of  this  kind, 
when  it  has  existed  for  a  great  length  of  time,  are, 
ulceration  of  the  ligaments,  acetabulum,  and  head  of 
the  bone,  which  allow  of  such  a  change  of  situation 
of  parts,  as  sometimes  to  give  the  limb  the  position 
pf  dislocation;  but  the  history  of  the  case  at  once 


PARTICULAR  DISLOCATIONS. 


61 


explains  to  the  medical  attendant  the  nature  of 
the  disease. 

Cause.  —  This  dislocation  may  be  caused  by  a  fall 
when  the  knee  and  foot  of  the  patient  are  turned 
inwards,  or  by  a  blow  whilst  the  limb  is  in  that 
position; — the  head  of  the  bone  being  thus  displaced 
upwards,  and  turned  backwards. 

In  the  reduction  of  this  dislocation,  the  following 
plan  is  to  be  adopted  :  —  let  the  patient  lose  from 
twelve  to  twenty  ounces  of  blood,  or  even  more  if 
he  be  a  very  strong  man;  then  place  him  in  a  warm 
bath,  at  the  heat  of  100",  and  gradually  increase  it 
to  110°,  until  he  feels  faint.  During  the  time  he  is 
in  the  warm  bath,  give  him  a  grain  of  tartarized 
antimony  every  ten  minutes  until  he  feels  some  nau- 
sea; then  remove  him  from  the  bafh  and  put  him 
in  blankets:  he  is  then  to  be  placed  between 
two  strong  posts,  about  ten  feet  asunder,  in  which 
-two  staples  are  fixed  ;  or  rings  may  be  screwed  into 
the  floor,  and  the  patient  be  laid  upon  it.  My  usu- 
al method  is,  to  place  him  on  a  table  covered  with 
a  thick  blanket,  upon  his  back;  then  a  strong  girth 
is  passed  between  his  pudendum  and  thigh,  and  this 
is  fixed  to  one  of  the  staples.  (See  plate.)  A  wetted 
linen  roller  is  tightly  applied  just  above  the  knee, 
and  upon  this  a  leathern  strap  is  buckled,  having  two 
straps  with  rings  at  right  apgles  with  the  circular 
part.  The  knee  is  to  be  slightly  bent,  but  not  quite 
at  a  right  angle,  and  brought  across  the  other  thigh 
a  little  above  the  knee  of  that  limb.  The  pulleys 
are  fixed  in  the  other  staple,  and  in  the  straps  above 
the  knee.  The  patient  being  thus  adjusted,  the  sur- 
geon slightly  draws  the  string  of  the  pulley,  and 
when  he  sees  that  every  part  of  the  bandage  is 
upon  the  stretch,  and  the  patient  begins  to  complain, 
he  waits  a  little  to  give  the  muscles  time  to  become 
fatigued;  he  then  draws  again,  and  when  the  pq.tient 


62 


PARTICULAR  DISLOCATIONS. 


suffers  much,  again  rests,  until  the  muscles  yield. 
Thus  he  gradually  proceeds  until  he  finds  the  head 
of  the  bone  approach  the  acetabulum.  When  it 
reaches  the  lip  of  that  cavity,  he  gives  the  pulley 
to  an  assistant,  and  desires  him  to  preserve  the  same 
state  of  extension,  and  the  surgeon  then  rotates  the 
knee  and  foot  gently,  but  not  with  a  violence  to  ex- 
cite opposition  in  the  muscles,  and  in  this  act  the 
bone  slips  into  its  place.  In  general,  it  does  not  re- 
turn with  a  snap  into  its  socket  when  the  pulleys  are 
employed,  because  the  muscles  are  so  much  relaxed, 
that  they  retain  not  sufficient  tone  to  act  with  vio- 
lence ;  and  the  surgeon  ascertains  the  reduction  only 
by  loosening  the  bandages,  and  comparing  the  length 
of  the  limbs.* 

It  often  happens  that  the  bandages  get  loose  be- 
fore the  extension  is  completed,  an  accident  which 
should  be  carefully  prevented  by  having  them  well 
secured  at  first  ;  but  if  they  require  to  be  renewed, 
this  should  be  expeditiously  performed,  to  prevent 
the  muscles  havinor  time  to  recover  their  tone. 

It  is  sometimes  necessary  for  the  operator  to  lift 
the  bone,  by  placing  his  arm  under  it  near  the  joint, 
when  there  is  difficulty  in  bringing  it  over  the  lip 
of  the  acetabulum;  or  a  napkin  may  be  passed  un- 
der the  bone,  as  near  the  head  as  possible,  and  by 


*  No  one  can  compare  the  certainty  and  regularity  with 
which  pulleys  act,  with  the  uncertain  and  often  discordant  exer- 
tions of  assistants,  and  not  be  convinced  of  the  decided  superior- 
ity of  the  former.  The  surgeon  can  rely  on  the  pulley  for  re- 
sults that  are  in  many  instances  lost  for  want  of  accurate  co-ope» 
ration  in  his  assistants,  or  from  their  becoming  fatigued  before 
the  muscles  of  the  patient  relax.  We  are  therefore  induced  to 
hope,  after  what  has  been  said  by  our  experienced  and  justly 
distinguished  author,  that  our  practitioners  will  provide  them- 
selves with  an  apparatus  which  at  a  small  expense,  insures  them 
against  loss  of  time,  or  injury  from  the  ignorance  and  impa* 
tience  of  assistants.  J.  D.  G, 


PARTICULAR  DISLOCATIONS. 


63 


its  means  an  assistant  may  raise  it.  After  the  re- 
duction, in  consequence  of  the  relaxed  state  of  the 
muscles,  great  care  is  required  in  removing  the  pa- 
tient to  his  bed. 

I  have  seen  reduction  of  the  bone  effected,  even 
where  the  extension  was  not  made  in  the  best  pos- 
sible direction  ;  for  when  the  muscles  have  not  had 
time  to  settle,  they  will  allow  the  bone  to  be  re- 
stored into  its  socket,  even  when  extension  is  made 
in  a  direction  not  the  most  favourable  for  its  reduc- 
tion. I  cannot  by  any  means  subscribe  to  the  me- 
thod adopted  by  the  late  Mr  Hey,  although  no  per- 
son ever  felt  greater  respect  for  his  talents,  more 
highly  appreciated  his  acquirements,  or  is  more  dis- 
posed to  pursue  the  study  of  the  profession  in  the 
mode  which  be  so  successfully  adopted.  The  direc- 
tion which  he  gave  to  a  limb,  in  the  case  which  he 
has  represented  of  this  accident,  was  one  little  cal- 
culated for  success,  in  cases  Avhere  the  means  were 
not  used  immediately  after  the  injury  had  been  sus- 
tained. But  I  state  this  with  great  deference,  be- 
cause I  am  not  sure,  that  in  all  respects,  I  under- 
stand the  description  of  the  method  which  he  adopt- 
ed ;  nor  do  I  think  that  I  should  be  able,  from  that 
description,  to  be  certain  that  I  was  pursuing  the 
means  by  which  he  succeeded. 

I  may  here  observe,  and  I  trust  without  ostenta- 
tion, that  the  methods  which  I  have  recommended, 
are  the  result  of  considerable  experience;  that  they 
have  been  successful  in  a  great  number  of  cases; 
and  that  they  have  very  rarely  failed,  under  the 
most  disadvantageous  circumstances.  They  may  re- 
quire a  little  variation,  from  some  slight  difference 
in  the  position,  but  this  will  only  be  an  exception  to 
a  general  rule,  and  will  very  rarely  occur. 

The  following  cases  will  serve  as  illustrations  of 
the  history  and  treatment  of  dislocations  on  the 


64 


PARTICULAR  DISLOCATIONS. 


dorsum  ilii;  the  first  of  them  points  out,  in  a  strik- 
ing manner,  the  evils  that  ensue  when  dislocation  of 
the  hip-joint  remains  unreduced,  and  the  advantages 
arising  from  the  use  of  pulleys  in  effecting  its  re- 
duction. It  shows  also  that. such  dislocation  may 
happen  in  a  strong  healthy  man,  even  after  he  has 
attained  the  age  of  sixty. 

Dislocation  on  the  Dorsum  Ilii. 

Case. — James  Ivory,  aged  sixfy-two,  of  Potten* 
send,  Herts,  on  the  7th  of  February,  1810,  was 
working  in  a  clay-pit  about  twenty-five  feet  below 
the  surface  of  the  earth,  when  a  large  quantity  of 
c\'dj  fell  in  upon  him,  while  he  was  in  the  act  of 
stooping  with  his  left  knee  bent  rather  behind  the 
other;  and  he  was  in  this  position  buried  under  the 
earth.  Being  soon  removed  from  this  perilous  situ- 
ation, and  carried  home,  a  surgeon  was  sent  for; 
who,  discovering  the  accident  to  be  a  dislocation,  di- 
rectly employed  some  men  to  extend  the  limb, 
whilst  he  attempted  to  push  the  head  of  the  bone 
into  the  acetabulum  ;  but  all  his  efforts  were  un- 
availing, as,  unfortunately  for  the  patient,  pulleys 
were  not  employed.  The  appearances  of  the  limb 
at  present,  when  nine  years  have  elapsed  since  the 
accident,  are  these  :  the  hmb  is  three  inches  and  a 
half  shorter  than  the  other,  and  the  patient  is  oblig- 
ed to  wear  a  shoe  having  an  additional  sole  of  three 
inches  on  that  side,  which  lessons,  though  it  does  not 
prevent,  his  halt  in  walking.  When  he  stands,  the 
foot  of  the  injured  limb  rests  upon  the  other;  the 
toes  are  turned  inwards,  and  the  knee,  which  is  ad- 
vanced upon  the  other,  is  also  inverted,  and  rests 
upon  the  side  of  the  patella  of  the  sound  limb,  and 
upon  the  vastus  internus  muscle  ;  it  is  also  bent,  and 


PARTICULAR  DISLOCATIONS. 


65 


cannot  be  conapletely  extended.  The  thigh,  from 
the  unemployed  state  of  several  of  the  muscles,  is 
very  much  wasted;  but  the  semi-tendinosus,  semi- 
membranosus, and  biceps,  in  consequence  of  the 
shortened  state  of  the  limb,  form  a  considerable 
rounded  projection  on  the  back  part  of  the  thigh. 
The  trochanter  major  is  seven-eighths  of  an  inch 
nearer  to  the  spine  of  the  ilium  of  the  injured  side 
than  of  the  other.  On  viewing  him  behind,  the  tro- 
chanter major  is  seen  projecting  on  the  injured  side 
much  farther  than  on  the  other  ;  the  situation  of  the 
head  of  the  bone  on  the  dorsum  ilii,  is  easily  per- 
ceived ;  and  when  the  limb  is  rotated  inwards,  it  is 
still  more  obvious.  The  spinous  processes  of  the 
ilia  are  of  an  equal  height.  In  the  sitting  posture, 
the  foot  is  turned  very  much  inwards,  and  the  knee 
is  placed  behind  the  other,  whilst  the  toe  only 
reaches  the  ground.  If  fatigued,  he  experiences 
pain  in  the  opposite  hip,  and  in  the  thigh  of  the  in- 
jured limb.  This  unfortunate  man  finds  it  an  ardu- 
ous task  to  gain  his  bread  by  his  labour,  as  he  can- 
not stoop  but  with  the  greatest  difficulty,  and  is 
therefore  obliged  to  seek  those  employments  which 
least  require  that  position.  When  he  attempts  to 
take  any  thing  from  the  ground,  he  bends  the  knee 
of  the  injured  limb  at  right  angles  with  the  thigh, 
and  throws  it  far  back.  He  can  now  stand  for  a  few 
seconds  upon  the  dislocated  limb,  but  it  was  twelve 
months  before  he  could  endure  that  posture.  When 
in  bed,  he  finds  it  painful  to  lie  on  the  injured  side. 
His  hip,  without  any  apparent  cause,  is  much  weaker 
at  some  times  than  at  others.  When  sitting  down 
to  evacuate  his  faeces,  he  is  obliged  to  support  him- 
self by  resting  the  injured  knee  against  the  tendo 
Achillis  of  the  other  leg,  placing  his  right  hand  on 
the  ground.  He  now  walks  with  two  sticks ;  at 
first  he  employed  crutches,  and  these  he  used  for 
9 


66 


PARTICULAR  DISLOCATIONS. 


twelve  months,  after  which  he  was  enabled  to  trust 
to  one  crutch  and  a  stick,  until  his  limb  acquired 
greater  strength.  In  getting  over  a  stile,  he  raises 
the  injured  limb  two  steps,  and  then  turns  over  the 
sound  limb;  but  this  he  cannot  accomplish  when  the 
steps  are  far  apart;  and  he  is  frequently  obliged 
either  to  turn  back,  or  to  take  a  circuitous  route. 
When  lying  with  his  face  downwards,  the  dislocated 
hip  projects  very  much.  He  sometimes  falls  in 
walking,  and  would  very  frequently  fall,  but  that  he 
takes  extreme  care,  as  the  least  check  to  his  motion 
throws  him  down.  The  knee  is  bent,  and  the  short- 
ening of  the  limb  partly  originates  in  that  circum- 
stance. 

The  following  cases  illustrate  the  method  of  re- 
duction detailed  in  the  preceding  pages,  and  show 
in  strong  colours,  the  advantages  to  be  derived  from 
constitutional  treatment,  and  the  use  of  pulleys. 

Case. — John  Forster,  aged  twenty-two  years, was 
admitted  into  the  Chester  Infirmary,  July  10th,  18 18, 
with  a  dislocation  of  the  thigh  on  the  dorsum  ilii, 
occasioned  by  a  cart  passing  over  the  pelvis.  Upon 
examination,  I  found  the  leg  shorter  than  the  other, 
and  the  knee  and  foot  turned  inwards.    The  patient 
being  firmly  confined  upon  a  table,  I  extended  the 
limb  by  pulleys,  for  fifty  minutes  without  success,  and 
he  was  returned  to  bed  for  three  hours;  after  which 
he  was  put  in  the  warai  bath  for  twenty  minutes, 
and  the  extension  was  repeated  for  fifteen  minutes, 
unsuccessfully  ;  I  therefore  took  twenty-four  ounces 
of  blood  from  him,  and  gave  him  forty  drops  of 
tinct.  opii.    Continuing  the  extension,  but  not  suc- 
ceeding in  producing  faintness,  I  gave  small  doses  of 
a  solution  of  tartrate  of  antimony,  which,  in  a  quar- 
ter of  an  hour,  produced  nausea ;  in  ten  minutes 
afterwards,  I  succeeded  in  reducing  the  limb,  and  in 


PARTICULAR  DISLOCATIONS. 


67 


less  than  a  fortnight  he  left  the  infirmary  quite  well. 
Unfortunately,  he  began  to  work  hard  immediately, 
and  brought  on  an  inflammation  of  the  hip,  of  which 
he  has  not  recovered. 

Chester,  S.  R.  Bennett. 


Sir: — I  beg  leave  to  forward  to  you  the  particu- 
lars of  the  following  case. 

Case.  —  John  Lee,  aged  thirty-three,  of  a  strong  and 
robust  constitution,  in  passing  over  a  foot-bridge,  Oc- 
tober 9th,  1819,  fell  from  a  height  of  about  four  feet 
on  a  large  stone,  and  dislocated  his  left  hip.  I 
did  not  see  him  until  the  4th  of  December,  when  I 
found  the  limb  full  three  inches  shorter  than  the 
other,  the  knee  turned  in,  the  foot  directed  over 
the  opposite  tarsus,  and  the  trochanter  major  brought 
nearer  the  spinous  process  of  the  ilium.  On  laying 
the  man  on  his  face,  the  head  of  the  femur  and 
trochanter  could  be  distinctly  seen  on  the  doisum 
ilii,  so  as  to  leave  not  the  slightest  doubt  of  the  na- 
ture of  the  injury.  With  the  assistance  of  a  neigh- 
bouring practitioner,  I  immediately  set  about  to  re- 
duce it ;  a  girth  was  applied  between  the  legs,  and 
a  bandage  over  the  knee,  to  fix  the  pulleys,  etc,  in 
the  usual  manner.  I  then  made  the  extension 
downwards  and  inwards,  crossing  the  opposite  thigh 
two-thirds  downwards;  and  immediately  when  the 
extension  was  commenced,  I  gave  him  a  solution  of 
two  grains  of  tartar  emetic,  which  was  repeated  five 
times  every  ten  minutes,  but  it  produced  very  slight 
nausea.  1  shortly  after  bled  him  to  sixty  ounces 
without  syncope  ;  and  after  keeping  up  the  extension 
gradually  for  about  two  hours,  with  all  the  force  one 
man  could  employ  with  the  pulleys,  we  found  the 
limb  as  long  as  the  opposite  ;  we  then  endeavoured 
to  lift  the  head  of  the  bone  over  the  acetabulum, 


68 


PARTICULAR  DISLOCATIONS. 


by  means  of  a  towel  under  the  thigh  and  over  one 
of  our  heads,  at  the  same  time  rotating  the  limb 
outwards  with  all  the  force  we  were  able  to  exert; 
the  foot  at  length  became  somewhat  turned  out,  and 
the  head  of  the  bone  to  be  less  distinctly  felt,  and  in 
about  half  an  hour  we  heard  a  grating  of  the  head 
of  the  bone,  when  the  man  instantly  exclaimed  it  was 
replaced;*  and,  upon  examination,  finding  the  foot 
turned  out,  the  limb  of  its  natural  length,  and  no 
appearance  of  the  head  of  the  bone  on  the  dorsum 
ilii,  we  concluded  it  must  be  within  the  acetabulum, 
and  desisted  from  any  further  violence,  put  the  man 
to  bed,  and  tied  his  legs  together  ;  his  foot  immedi- 
ately became  sensible,  which  it  had  not  been  before 
since  the  accident,  and  he  altogether  felt  easier.  A 
large  blister  was  applied  over  the  trochanter,  and  he 
slept  well  in  the  night,  and  complained  of  pain  only 
in  the  perineum  and  just  above  the  knee,  where  the 
bandages  had  been  applied  ;  there  was  no  subse- 
quent fever,  nor  any  unpleasant  symptom  what- 
ever. 

In  a  few  days  the  man  could  bear  slight  flexion 
and  extension  without  pain,  and  in  a  week  some  de- 
gree of  rotation  ;  the  limb  became  gradually  stronger, 
and  the  power  of  motion  so  increased,  that  on  the 
twelfth  day  he  could  by  himself  bring  the  thigh  at 
right  angles  with  the  body.  He  was  now  taken  out 
of  bed;  bandages  were  applied  round  the  thigh  and 
pelvis;  and  he  could  stand  perfectly  upright,  so  as 
to  walk  with  his  heel  on  the  ground  with  the  assist- 
ance of  crutches  :  and  from  exercise,  he  grew  so 
rapidly  stronger,  that  on  the  twenty-second  day  he 
left  off  one  crutch,  and  on  the    twenty-fifth  the 

*  In  dislocations  which  have  long  remained  unreduced,  the 
bone  does  not  usually  snap  into  the  socket  at  its  reduction. — 
A.  C, 


PARTICULAR  DISLOCATIONS. 


69 


other.  In  a  month  he  was  able  to  walk  without  a 
stick  ;  and  in  five  weeks,  having  particular  business, 
he  walked  nearly  twenty  miles,  perfectly  upright, 
and  without  the  least  limping. 

Collumpton,  Devon.  Your's  very  truly, 

Jan,  27,  1820.  S.  Nott. 

The  following  case  forms  a  striking  contrast  to  the 
preceding,  and  to  some  of  those  hereafter  related. 

Case.  — I  was  desired  to  visit  a  man  aged  twenty- 
eight  years,  who,  by  the  overturning  of  a  coach,  had 
dislocated  his  left  hip  more  than  five  weeks  before  ; 
and  who  had  been  declared  not  to  have  a  dislocation, 
although  the  case  was  extremely  well  marked.  His 
leg  was  full  two  inches  shorter  than  the  other;  his 
knee  and  foot  Avere  turned  inwards  ;  and  the  inner 
side  of  the  foot  rested  upon  the  metatarsal  bones  of 
the  other  leg.  The  thigh  w^as  slightly  bent  towards 
the  abdomen,  and  the  knee  was  advanced  over  the 
other  thigh.  The  head  of  the  thigh-bone  could  be 
distinctly  felt  upon  the  dorsum  of  the  ilium;  and 
when  the  two  hips  were  compared,  the  natural  round- 
ness of  the  dislocated  side  had  disappeared.  I  used 
only  mechanical  means  in  my  attempts  at  reduction; 
and  although  I  employed  the  pulleys,  and  varied  the 
direction  of  repeated  extensions,  I  could  not  succeed 
in  replacing  the  bone,  and  this  person  returned  to 
the  country  with  the  dislocation  unreduced. 

The  following  case  was  communicated  to  me  by 
Mr  Norwood,  surgeon,  Hertford. 

Case.  —  William  Newman,  a  strong  muscular  man,  • 
nearly  thirty  years  of  age,  was  admitted  into  Guy's 
Hospital,  on  Wednesday,  December  4th,  1812,  under 
the  care  of  Mr  Astley  Cooper,  for  a  dislocation  of 
the  hip-joint.    In  springing  from  the  shafts  of  a  wag- 


70 


PARTICULAR  DISLOCATIONS. 


on,  on  Thursday,  November  7th,  his  foot  slipped, 
and  his  hip  was  driven  against  the  wheel  with  con- 
siderable force.  He  immediatelj  fell,  and  being 
found  unable  to  walk,  was  carried  to  Kingston  Work- 
house, which  was  near  the  place  where  the  accident 
happened.  On  the  evening  of  that  day,  he  was  ex- 
amined by  a  medical  man,  but  the  nature  of  the  acci- 
dent was  not  ascertained.  He  remained  at  Kings- 
ton until  the  30th  of  November,  and  was  then  re- 
moved to  Guildford,  his  place  of  residence,  and  from 
thence,  on  the  4th  of  December,  to  Guy's  Hospital. 
On  examination,  the  head  of  the  thigh-bone  was 
found  resting  on  the  dorsum  ilii;  the  trochanter  was 
thrown  forward  towards  the  anterior  superior  spi- 
nous process  of  the  ilium.  The  knee  and  foot  were 
turned  inwards,  and  the  limb  was  shortened  one  inch 
and  a  half;  the  great  toe  rested  upon  the  metatarsal 
bone  of  the  other  foot,  and  there  was  but  little  mo- 
tion in  the  limb. 

On  Saturday,  the  7th  of  December,  being  thirty 
days  after  the  accident,  an  extension  was  made  to 
reduce  the  limb  ;  and  previously  to  the  application 
of  the  bandage,  he  was  bled  to  twenty-four  ounces 
from  his  arm  ;  in  about  ten  minutes  after  this  he 
was  put  into  a  warm  bath,  where  he  remained  until 
he  became  faint,  which  happened  in  fifteen  minutes; 
he  then  had  a  grain  of  tartarized  antimony  given 
him,  which  was  repeated  in  sixteen  minutes,  as  the 
first  dose  did  not  produce  nausea.  The  most  dis- 
tressing nausea  was  now  quickly  produced,  but  he 
did  not  vomit ;  and  while  under  the  influence  of  this 
debilitating  cause,  he  was  carried  into  the  operating 
theatre  in  a  state  of  great  exhaustion.  Being  placed 
on  a  table  on  his  left  side,  the  bandage  was  applied 
in  the  usual  manner  to  fix  the  pelvis,  and  the  pulleys 
were  fastened  to  a  strap  around  the  knee  ;  the  thigh 
was  drawn  obliquely  across  the  other,  not  quite  two 


PARTICULAR  DISLOCATIONS. 


71 


thirds  of  its  length  downwards,  and  the  extension 
was  continued  for  ten  minutes,  when  the  bone  slipped 
into  its  socket.  The  man  was  discharged  from  the 
hospital  in  three  weeks  from  the  period  of  his  ad- 
mission, making  rapid  progress  towards  a  recovery 
of  the  perfect  use  and  strength  of  the  limb. 

For  the  history  of  the  following  case,  I  am  oblig- 
ed to  Mr  Thomas,  apothecary  to  St  Luke's  Hos- 
pital, who  attended  to  it  while  acting  as  dresser  at 
St  Thomas's  Hospital. 

Case, —  William  Chapman,  aged  fifty  years,  was 
admitted  into  St  Thomas's  Hospital,  on  Thursday, 
September  10th,  1812,  with  a  dislocation  of  the  left 
hip  upon  the  dorsum  ilii,  which  was  occasioned  by 
the  mast  of  a  ship  falling  upon  the  part  and  throw- 
ing him  down,  on  the  Wednesday  six  weeks  prior  to  his. 
admission  into  the  hospital.  It  was  reduced  on  Fri- 
day, the  11th  of  September,  in  the  following  man- 
ner. The  patient  was  bled  by  opening  a  vein  in 
each  arm,  and  thirty-four  ounces  of  blood  were  taken 
away.  He  was  then  put  into  a  warm  bath,  and  a 
grain  of  tartanzed  antimony  given  to  him,  which 
was  repeated  every  ten  minutes  ;  this,  with  the  pre- 
vious means,  produced  fainting  and  nausea. 

The  patient  was  then  placed  on  a  table  on  hi& 
right  side,  and  a  girth  was  carried  between  his 
thighs  and  over  his  pelvis,  so  as  completely  to  con- 
fine it ;  a  wetted  roller  was  applied  above  the  knee, 
and  upon  it  a  leathern  belt,  with  rings  for  the  pul- 
leys. The  extension  was  then  made  in  a  direction 
causing  the  dislocated  thigh  to  cross  the  other  be- 
low its  middle,  and  in  half  an  hour  the  reduction 
was  accomplished. 

The  three  following  cases  show  that  we  are  not 
to  despair  of  success,  even  when  a  considerable  time 
has  elapsed  after  the  accident. 


72 


PARTICULAR  DISLOCATIONS. 


Case.  —  Mr  Mayo  has  mentioned  the  case  of 
Wiiliarn  Honey,  who  came  into  the  hospital  in 
August,  1812:  the  dislocation  had  taken  place  seven 
weeks  before,  and  was  reduced  the  day  after  his  ad- 
mission;  he  was  discharged,  cured,  on  the  18th  of 
November.  This  was  a  dislocation  on  the  dorsum 
ilii. 

Case,  —  Mr  Tripe,  surgeon  at  Plymouth,  has  • 
sent  to  the  Medico-Chirurgical  Society,  an  account 
of  a  case  of  dislocation  of  the  thigh-bone  on  the 
dorsum  ilii,  which  had  happened  seven  weeks  and 
one  day  prior  to  his  making  an  extension,  in  which 
he  was  so  fortunate  as  to  succeed  in  restoring  the 
bone  to  its  natural  situation. 

The  following  instances  prove,  indeed,  that  the 
dislocation  on  the  dorsum  ilii  may  be  reduced  with- 
out pulleys  ;  but  they  show  at  the  same  time,  how 
desirable  that  mechanical  aid  would  have  been,  es- 
pecially in  the  two  first  instances. 

Case. —  William  Piper,  aged  twenty-five  years, 
sustained  an  injury  from  the  wheel  of  a  cart,  laden 
with  hay,  which  passed  between  his  legs  and  over 
the  upper  part  of  his  right  thigh.  Mr  Holt,  sur- 
geon at  Tottenham,  was  sent  for  nearly  a  month 
after  the  accident  had  happened;  he  found  him  in 
great  pain,  attended  with  fever,  and  with  much  local 
inflammation  and  tension.  He  bled  him  largely, 
purged  him  freely,  and  applied  leeches.  The  in- 
jured leg  was  shorter  than  the  other,  and  the  head 
of  the  bone  was  seated  upon  the  dorsum  ilii;  the 
knee  and  foot  were  turned  inwards. 

As  I  visited  Tottenham  frequently  at  that  time, 
Mr  Holt  asked  me  to  accompany  him  to  see  the 
man,  and  we  agreed  on  the  propriety  of  making  a 
trial  at  reduction.  Mr  Holt  and  myself,  assisted  by 
five  strong  men,  exerted  our  best  endeavours  for 


PARTICULAR  DISLOCATIONS. 


73 


that  purpose.  Repeatedly  fatigued,  we  were  sev- 
eral times  obliged  to  pause  and  then  renew  our  at- 
tempts. At  length  exhausted,  we  were  about  to 
abandon  any  further  trial,  but  agreed  to  make  one 
last  effort ;  when,  at  fifty-two  minutes  after  the 
commencement  of  the  attempt,  the  bone  slipped 
info  its  socket. 

Case,  —  In  a  case  also,  which  I  attended  with 
Mr  Dyson,  in  Fore  Street,  I  succeeded  in  reducing 
the  limb  without  the  use  of  pulleys  ;  but  the  vio- 
lence used  was  so  great,  and  the  extension  so  une- 
qual (our  fatigue  being  nearly  as  severe  as  that  of 
the  patient),  that  I  am  confident  no  person  who  had 
used  pulleys  in  dislocation  of  the  hip,  would  have 
recourse  to  any  other  mode,  excepting  in  dislocation 
into  the  foramen  ovale. 

Case,  —  Mary  Bailey,  aged  seven  years,  was  ad- 
mitted into  Guy's  Hospital,  June  16th,  1819,  under 
the  care  of  Mr  Astley  Cooper,  for  a  dislocation  of 
the  OS  femoris  upwards  on  the  dorsum  ilii.  This 
accident  was  occasioned  by  the  child  swinging  on 
the  shaft  of  a  cart,  Avhich,  being  insecurely  prop- 
ped, suddenly  gave  way,  and  she  fell  to  the  ground 
upon  her  side.  The  nature  of  the  accident  was 
perfectly  evident ;  the  limb  on  the  dislocated  side 
was  at  least  two  inches  shorter  than  the  other;  the 
toe  rested  on  the  tarsus  of  the  opposite  foot,  and 
was  turned  inwards ;  the  knee  was  also  inverted 
and  rested  on  the  other.  The  child  was  admitted 
into  the  hospital  at  half-past  five  in  the  afternoon, 
the  accident  having  happened  rather  more  than 
half  an  hour  before.  Where  so  little  resistance 
was  expected  the  pulleys  appeared  unnecessary,  and 
towels  were  substituted,  one  being  applied  above 
the  knee,  and  the  other  between  the  pudendum  and 
thigh ;  then,  the  knee  being  bent,  and  the  thigh 
brought  across  the  other  just  above  the  knee,  gra- 

10 


74 


PARTICULAR  DISLOCATIONS. 


dual  extension  was  made,  and  in  about  four  minutes 
the  head  of  the  bone  suddenly  snapt  into  its  socket. 
On  the  seventh  day  the  child  was  walking  in  her 
ward,  and  suffered  little  inconvenience. 

To  Mr  Daniell,  one  of  Mr  Lucas's  dressers,  I  am 
obliged  for  the  foregoing  particulars  ;  he  having  re- 
duced the  limb  in  the  presence  of  many  of  the 
students. 

In  the  following  case  the  extension  was  made  at 
the  ankle,  and  it  is  consequently  w^orthy  of  notice. 

Case,  —  My  dear  Sir:  — Wilham  Sharpe,  an  ath- 
letic young  man,  in  wTestling  received  a  fall;  his  an- 
tagonist falling  with  and  upon  him,  their  legs  were 
so  entangled  that  he  cannot  say  how  he  came  to  the 
ground.  He  complained  of  great  pain  in  the  hip^ 
and  was  incapable  of  rising.  About  twenty  minutes 
after  the  accident,  I  found  him  lying  on  his  belly  in 
the  field  where  it  had  occurred,  and  the  left  limb 
in  a  trifling  state  of  abduction,  shortened,  and  the 
knee  and  foot  turned  inwards,  the  prominency  of  the 
trochanter  gone,  and  the  head  of  the  bone  obscurely 
felt  on  the  dorsum  ilii.  He  was  conveyed  home,  and 
in  order  to  reduce  the  dislocation,  for  such  I  consid- 
ered it,  I  placed  the  man  on  his  right  side  diagonally 
across  a  four-post  bedstead.  The  centre  of  a  large 
sheet  rolled  up  was  passed  in  front  and  behind  the 
body,  and  fastened  to  the  upper  bed-post,  as  low  as 
possible.  The  centre  of  a  napkin,  rolled  in  like 
manner,  was  then  applied  upon  the  dorsum  ilii,  be- 
tween its  crista  and  the  dislocated  bone ;  and  each 
extremity  being  brought  under  the  sheet,  forwards 
and  backwards,  was  reflected  over  it  and  tied  in  the 
centre,  by  which  means  I  hoped  (o  keep  the  pelvis 
secure;  the  counter-extending  force  was  applied 
above  the  ankle  (it  appearing  to  me  to  interfere  less 
with  the  muscles  upon  the  thigh),  first,  by  rolling 


PARTICULAR  DISLOCATIONS. 


75 


round  a  wetted  towel,  and  then  placing  upon  this 
the  end  of  a  long  or  jack-towel :  three  men  were 
now  directed  to  pull  gradually  -and  steadily;  and 
when  I  perceived  that  the  head  of  the  femur  was 
brought  down  to  the  edge  of  the  acetabulum,  I 
raised  it  a  little  with  my  clasped  hands  placed  under 
the  upper  part  of  the  thigh',  and  immediately  the 
head  of  the  bone  entered  the  cotyloid  cavity  with  a 
smart  snapping  noise.  The  man  had  considerable 
pain  about  the  hip  and  knee  for  some  time,  but  is 
now  quite  well. 

I  am,  dear  Sir, 
JYottingham,  Your's  truly, 

August  8th,  1819.  Henry  Oldknow. 

Dudley,  January  \9th,  1824. 
Case,  —  Dear  Sir :  • —  A  youth,  about  sixteen  or 
eighteen  years  of  age,  while  at  his  work  in  a  pit, 
was  buried  under  a  fall  of  coals  ;  and  besides  being 
severely  injured  in  several  other  parts  of  his  body, 
had  one  hip  dislocated  on  the  dorsum  of  the  ilium, 
and  the  same  thigh  broken  about  the  middle  of  the 
bone.  As  the  reduction  of  the  hip  was,  of  course, 
impracticable,  the  thigh  was  bound  up  in  the  usual 
manner,  and  treated  without  any  reference  to  the 
dislocation  of  the  joint,  with  a  hope  that  when  the 
thigh-bone  was  re-united,  the  hip  might  possibly  be 
reduced.  At  the  end  of  live  weeks,  the  bone  ap- 
pearing tolerably  firm,  I  had  a  very  careful  but  un- 
remitting extension  of  the  limb  made  by  means  of 
pulleys,  and,  in  less  than  half  an  hour,  had  the  satis- 
faction of  feeling  the  head  of  the  bone  re-enter  the 
socket.  It  is  very  probable  that  the  reduction  would 
have  been  accomplished  in  less  time,  had  I  dared  to 
allow  a  more  powerful  extension  of  the  limb,  but  1 
very  much  feared  lest  a  separation  of  the  newly 


76 


PARTICULAR  DISLOCATIONS. 


united  bone  should  be  produced  by  it.  The  patient 
became  so  upright  as  to  show  scarcely  any  signs  of 
lameness  afterwards. 

1  have  met  with  several  instances  of  these  acci- 
dents conjoined  with  another  injury,  which  at  first 
sight  presented  a  complication  sufficiently  embar- 
rassing, but  without  being,  in  reality,  productive  of 
much  additional  difficulty.  I  allude  to  cases,  in 
which,  with  dislocation  of  one  hip,  there  has  been  a 
fracture  of  the  bone  of  the  opposite  thigh.  In  such 
circumstances,  I  have  fixed  some  splints  temporarily, 
but  very  firmly,  upon  the  broken  limb,  and  then, 
turning  the  patient  on  that  side,  have  proceeded  to 
the  reduction  of  the  dislocated  hip  in  the  usual  way. 
After  this  has  been  accomplished,  I  have  taken  the 
splints  from  the  broken  limb,  and  bound  it  up  again 
in  the  customary  manner ;  and  every  case  which  1 
have  seen  has  done  well,  without  any  additional  in- 
convenience. 

\  once  witnessed  a  case,  which  I  mention  rather 
for  its  singularity  than  for  any  practical  inference 
which  it  furnishes.  —  A  man  had  received,  I  forget 
how,  a  severe  hurt  on  one  of  his  hips.  When  laid 
on  a  bed  for  examination,  the  thigh-bone  was  found 
not  to  be  broken,  and  the  limbs  were  exactly  of  the 
same  length  ;  but  the  foot  of  the  injured  side  turned 
somewhat  inwards,  and  any  attempt  to  move  the 
hip-joint  was  extremely  painful.  On  a  more  careful 
examination  of  the  parts  about  the  hip,  it  was  plain 
that  the  thigh-bone  was  dislocated,  and  that  its  head 
was  on  the  dorsum  of  the  ilium,  and  yet  the  limb 
seemed  not  at  all  shortened.  A  brief  enquiry,  how- 
ever, led  to  an  explanation  of  this  apparent  anomaly. 
It  appeared  that  the  opposite  thigh-bone  had  been 
formerly  broken,  and  had  united  in  such  a  way  as 
to  leave  the  limb  several  inches  shorter  than  it  had 
originally  been ;  and  the  dislocation  of  the  other 


PARTICULAR  DISLOCATIONS. 


77 


thigh  upwards,  had  now  brought  that  to  a  corre- 
sponding length.  It  is  scarcely  needful  to  add,  that 
the  reduction  of  the  dislocation  restored  the  patient 
to  his  former  lameness,  and  to  the  deformity  produc- 
ed by  limbs  of  unequal  length. 

I  remain,  dear  Sir, 

Your  most  obedient  servant. 
To  Sir  Astley  Cooper,  John  Badley. 

Dislocation  of  the  Thigh  upon  the  Dorsum  Ilii,  with 
Fracture  of  the  Thigh-Bone, 

Case, — Abraham  Harman,  aged  thirteen  years, 
a  patient  under  Mr  Forster,  in  Guy's  Hospital,  gave 
the  following  account  of  his  accident. 

About  four  months  prior  to  this  time,  he  drove 
his  master's  horses  to  a  chalk-pit ;  he  went  down 
into  the  pit  to  pack  the  chalk,  and  to  break  it  into 
small  pieces,  and  while  he  was  thus  occupied,  the 
side  of  the  pit  gave  way,  and  a  large  piece  of  chalk 
striking  him  violently  on  the  hip,  knocked  him  down. 
Being  immediately  taken  to  a  neighbouring  public- 
house,  a  surgeon  was  sent  for.  The  thigh  was  dis- 
covered to  be  fractured  near  its  middle,  but  very  con- 
siderable contusions  prevented  the  dislocation  from 
being  at  first  discovered.  Fomentation  and  other 
means  of  reducing  the  swelling  at  the  hip  having 
been^  employed,  it  was  ascertained  that  the  thigh 
was  also  dislocated,  and  some  attempts  were  made 
to  reduce  it ;  but  the  fracture  would  not  then  bear 
the  extension,  and  the  boy  was  sent  to  the  hospital. 
No  attempts  have  since  been  made  to  reduce  the 
bone. 

This  case  presented  unusual  difficulties ;  and  the 
probability  is,  that  dislocation  thus  complicated  with 
fracture,  will,  generally,  not  admit  of  reduction ;  as 


78 


PARTICULAR  DISLOCATIONS. 


an  extension  cannot  be  made,  until  three  or  four 
months  have  elapsed  from  the  accident,  and  then 
only  with  strong  splints  upon  the  thigh,  to  prevent 
the  risque  of  disuniting  the  fracture. 

Marlborough,  Feb,  12,  1823. 

Case. — Sir:  — Permit  me  to  send  you  the  fol- 
lowing case  of  dislocation  of  the  thigh-bone  on  the 
dorsum  of  the  ilium. 

George  Davies,  aged  thirty-five,  on  the  first  of 
the  present  month,  in  descending  a  flight  of  steps 
at  a  mill  in  this  neisfhbourhood,  with  a  sack  of 
wheat  on  his  back,  missed  a  step  or  two,  and  \u  en- 
deavouring to  regain  his  footing,  the  whole  weight 
of  the  load  fell  upon  him,  and  the  violence  of  the 
shock  bore  him  down  several  steps  lower,  where 
he  lay  totally  incapable  of  further  motion  till  as- 
sistance was  procured. 

He  was  then  conveyed  to  the  adjoining  village. 
On  examination,  the  limb  was  found  considerably 
shorter  than  its  fellow,  the  foot  turned  inwards,  and 
resting  upon  the  tarsus  of  the  other  leg.  The  head 
of  the  bone  was  distinctly  felt,  lodged  among  the 
glutei  muscles.  All  the  other  symptoms  were  un- 
equivocal. In  about  three  hours  after  the  occur- 
rence of  the  accident,  due  prepdration  having  been 
made,  thirty  ounces  of  blood  were  taken  from  the 
arm,  the  pulleys  were  adjusted  according  to  your 
directions,  and  gradual  extension  being  made,  the 
head  of  the  bone  was  eventually  brought  on  a  line 
with  the  acetabulum;  a  towel  was  now  passed  un- 
der the  thigh,  by  which  means  the  bone  was  elevat- 
ed, and  suddenly,  with  an  audible  snap,  it  slipped 
into  its  proper  cavity.  The  man  is  going  on  well, 
but  as  he  is  still  suffering  from  the  effect  of  the  con- 


PARTICULAR  DISLOCATIONS.  79 

tusion,  he  has  not  been  allowed  to  make  much  use 
of  his  limb. 

Your's  respectfully, 

T.  Maurice. 

P.  S.  The  reduction  was  accomplished  in  about 
ten  minutes. 


DISLOCATION  DOWNWARDS,  OR  INTO  THE  FORAMEN 
OVALE. 

Anatomy.  —  The  foramen  ovale  is  formed  by  the 
junction  of  two  bones,  the  ischium  and  the  pubes ; 
it  is  situated  below  the  acetabulum,  and  is  somewhat 
near  the  axis  of  the  body.  It  is  filled  by  a  ligament 
which  proceeds  from  the  edges  of  the  foramen,  and 
has  an  opening  in  its  upper  and  anterior  part,  to 
permit  the  passage  of  the  obturator  blood-vessels^ 
and  the  obturator  neive.  It  is  covered  on  its  ex- 
ternal  and  internal  surface  by  the  obturator  exter- 
nus  and  obturator  internus  muscles. 

Mode  of  accident.  —  This  dislocation  happens 
when  the  thighs  are  widely  separated  from  each 
other.  The  ligamentum  teres  and  the  lower  part 
of  the  capsular  ligament  are  torn  through,  and  the 
head  of  the  bone  becomes  situated  in  the  posterior 
and  inner  part  of  the  thigh,  upon  the  obturator  ex- 
ternus  muscle. 

It  has  been  erroneously  supposed,  that  the  liga-  ' 
mentum  teres  is  not  torn  through  in  this  dislocation; 
because  in  the  dead  body,  when  the  capsular  liga- 
ment is  divided,  the  head  of  the  bone  can  be  drawn 
over  the  lower  edge  of  the  acetabulum  without 
tearing  the  ligamentum  teres.  But  the  dislocation 
in  the  foramen  ovale  happens  whilst  the  thighs  are 


80 


PARTICULAR  DISLOCATIONS. 


widely  separated,  during  which  act  the  hgatnentum 
teres  is  upon  the  stretch ;  and  when  the  head  of 
the  bone  is  thrown  from  the  acetabulum,  this  liga- 
ment is  torn  through  before  it  entirely  quits  the  ca- 
vity. 

Symptoms,  —  The  limb  is  in  this  case  two  inches 
longer  than  the  other.  The  head  of  the  bone  can 
be  felt  by  pressure  of  the  hand,  upon  the  inner  and 
upper  part  of  the  thigh  towards  the  perinaeum,  but 
only  in  very  thin  persons.  The  trochanter  major  is 
less  prominent  than  on  the  opposite  side.  The  body 
is  bent  forwards  by  the  tension  of  the  psoas  and  ilia- 
cus  internus  muscles.  The  knee  is  considerably  ad- 
vanced if  the  body  be  erect;  it  is  widely  separated 
from  the  other,  and  cannot  be  brought,  without  great 
difficulty,  near  the  axis  of  the  body  to  touch  the 
other  knee,  in  consequence  of  the  extension  of  the 
glutei  and  pyriformis  muscles.  The  foot,  though 
widely  separated  from  the  other,  is  generally  neither 
turned  outwards  nor  inwards,  although  1  have  seen 
it  varying  a  little  in  this  respect  in  different  instan- 
ces; but  the  position  of  the  foot  does  not  in  this 
case  mark  the  accident.  The  bent  position  of  the 
body,  the  separated  knees,  and  the  increased  length 
of  the  limb,  are  the  diagnostic  symptoms.  The  po- 
sition of  the  head  of  the  bone  is  below,  and  a  little 
anterior  to,  the  axis  of  the  acetabulum  ;  and  a  hol- 
low is  perceived  below  Poupart's  ligament. 

Dissection.  —  There  is  an  excellent  preparation  of 
this  accident  in  the  collection  at  St  Thomas's  Hospi- 
tal, which  I  dissected  many  years  ago.  The  head 
of  the  thigh-bone  was  found  resting  in  the  foramen 
ovale,  but  the  obturator  externus  muscle  was  com- 
pletely absorbed,  as  welt  as  the  ligament  naturally 
occupying  the  foramen,  now  entirely  filled  by  bone. 
Around  the  foramen  ovale  bony  matter  was  deposit- 
ed so  as  to  form  a  deep  cup,  in  which  the  head  of 


PARTICULAR  DISLOCATIONS.  81 

the  thigh-bone  was  inclosed,  but  in  such  a  manner  as 
to  allow  of  considerable  motion;  the  cup  thus  form- 
ed, surrounded  the  neck  of  the  thigh-bone  without 
touching  it,  and  so  inclosed  its  head,  that  it  could  not 
be  removed  from  its  new  socket  without  breaking  its 
edges.  The  inner  side  of  this  new  cup  was  extreme- 
ly smooth,  not  having  the  least  ossific  projection  at 
any  part  to  impede  the  motion  of  the  head  of  the. 
bone,  which  was  only  restrained  by  the  muscles  from 
extensive  movements.  The  original  acetabulum  was 
half  filled  by  bone,  so  that  it  could  not  have  receiv- 
ed the  ball  of  the  thigh-bone  if  an  attempt  had  been 
made  to  return  it  into  its  natural  situation.  The 
head  of  the  thigh-bone  was  very  little  altered;  its 
articular  cartilage  still  remained ;  the'  ligamentum 
teres  was  entirely  broken,  and  the  capsular  ligament 
was  partially  torn  through  ;  the  pectinalls  muscle 
and  adductor  brevis  had  been  lacerated,  but  were 
united  by  tendon;  the  psoas  muscle  and  lliacus  in- 
ternus,  the  glutei  and  pyriformis,  were  all  upon  the 
stretch.  Nothing  can  be  more  curious,  or,  to  the 
surgeon  and  physiologist,  more  beautiful,  than  the 
changes  produced  by  this  neglected  accident,  which 
exemplify  the  resources  of  nature  in  producing  re- 
storation. 

Reduction, — The  reduction  of  this  dislocation,  is,  in 
general,  very  easily  effected.  If  the  misfortune  be 
of  recent  occurrence,  it  is  requisite  to  place  the  pa- 
tient upon  his  back,  to  separate  the  thighs  as  widely 
as  possible, and  to  place  a  girth  between  the  puden- 
dum and  the  upper  part  of  the  luxated  thigh,  fixing 
it  to  a  staple  in  the  wall.  The  surgeon  then  puts 
his  hand  upon  the  ankle  of  the  dislocated  side,  and 
draws  it  over  the  sound  leg,  or,  if  the  thigh  be  very 
large,  behind  the  sound  limb,  and  the  head  of  the 
bone  slips  into  its  socket.  I  saw  a  dislocation  thus 
reduced,  which  had  happened  very  recently,  and 
11 


82 


PARTICULAR  DISLOCATIONS. 


which  Avas  subjected  to  an  extension  in  St  Thomas's 
Hospital,  almost  immediately  after  the  patient's  ad- 
mission. In  a  similar  case,  the  thigh  might  be  fixed 
by  a  bed-post  received  between  the  pudendum  and 
the  upper  part  of  the  limb,  and  the  leg  be  carried 
inwards  across  the  other.  But  in  general  it  is  re- 
quired to  fix  the  pelvis  by  a  girth  passed  around 
it,  and  crossed  under  that  which  passes  around  the 
thigh,  to  which  pulleys  are  to  be  attached,  otherwise 
the  pelvis  will  move  in  the  same  direction  with  the 
head  of  the  bone.    (See  Plate.) 

In  those  cases  in  which  the  dislocation  has  existed 
for  three  or  four  weeks,  it  is  best  to  place  the  pa- 
tient upon  his  sound  side  ;  to  fix  the  pelvis  by  one 
bandage,  and  to  carry  under  the  dislocated  thigh 
another  bandage,  to  which  the  pulleys  are  to  be 
affixed  perpendicularly  ;  then  to  draw  the  thigh  up- 
wards, whilst  the  surgeon  presses  down  the  knee 
and  foot,  to  prevent  the  lower  part  of  the  limb  from 
being  drawn  with  the  thigh-bone.  Thus  the  limb  is 
used  as  a  lever  of  very  considerable  power.  Great 
care  must  be  taken  not  to  advance  the  leg  in  any 
considerable  degree,  otherwise  the  head  of  the  thigh- 
bone will  be  forced  behind  the  acetabulum  into  the 
ischiatic  notch,  from  whence  it  cannot  be  afterwards 
reduced. 


Dislocation  of  the  right  Thigh  into  the  Foramen 
Ovale, 

Case. — While  a  gentleman  was  riding  on  horse- 
back on  the  4th  of  January,  181<],  the  animal  sud- 
denly started  to  the  right  side  ;  and  as  the  rider 
endeavoured  to  keep  his  seat  by  the  pressure  of  the 
right  thigh  against  the  saddle,  he , was  thrown,  and 
from  the  fall  received  a  severe  contusion  upon  his 
head,  which  produced  alarming  symptoms.    On  the 


PARTICULAR  DISLOCATIONS. 


83 


following  day  it  Avas  observed  that  the  riglit  thigh 
was  useless,  and  that  the  knee  was  raised  and  could 
not  be  brought  into  a  straight  line  with  the  other, 
having  at  the  same  time  a  direction  outwards,  which 
required  it  to  be  tied  to  the  other  knee  :  the  symp- 
toms of  injury  to  the  head  precluded,  at  this  time, 
the  attempt  at  reduction.  In  fourteen  days  he  was 
so  far  recovered  that  he  was  able  to  rise  from  his 
bed,  and  in  a  month  he  began  to  walk  with 
crutches. 

On  November  Isr,  1818,  I  first  saw  him;  and  the 
appearances  of  the  injured  limb  were  then  as  fol- 
low :  —  the  thigh  was  longer  than  the  other  by  the 
length  of  the  patella;  the  knee  was  advanced;  and 
when  he  was  in  the  recumbent  posture,  the  injured 
leg  could  not  be  drawn  down  to  the  same  length 
with  the  other.  The  upper  part  of  the  thigh-bone 
was  thrown  backwards,  so  as  to  render  the  hollow 
of  the  groin  on  the  injured  side  deeper  than  that 
on  the  other.  The  toes  were  rather  everted,  but 
when  the  body  was  erect,  were  capable  of  resting 
on  the  ground,  though  the  heel  was  not.  The  head 
of  the  bone  could  not  be  felt,  and  the  trochanter 
was  much  less  prominent  than  usual.  When  the 
upper  part  of  the  thigh-bone  was  pressed  against 
the  new  acetabulum,  and  moved,  there  was  a  sen- 
sation of  friction  between  two  cartilaginous  surfaces, 
which,  although  not  easily  described,  is  readily  dis- 
tinguished from  the  crepitus  occasioned  by  a  frac- 
tured bone.  In  a  sitting  posture  the  injured  leg 
was  two  inches  longer  than  the  other;  and  to  that 
degree  the  knee  was  projected  beyond  the  sound 
one.  In  progression  the  knee  was  bent  ;  and  the 
body  being  thrown  forwards  the  patient  rested 
chiefly  upon  his  toe,  and  halted  exceedingly  in  walk- 
ing. The  sartorius  and  gracilis  muscles  were  very 
much  put  upon  the  stretch.  At  first  he  suflTered 
much  from  pain  in  the  dislocated  hip  and  thigh,  but 


PARTICULAR  DISLOCATIONS. 


is  now  free  from  pain,  unless  when  he  attempts  to 
stand  on  that  limb  onljc  His  toe,  at  first,  was  with 
difficulty  brought  to  the  ground,  but  he  is  now  im- 
proved in  walking ;  for  when  he  first  made  trial, 
with  the  assistance  of  a  crutch  and  stick,  he  could 
not  exceed  half  a  mile,  but  he  is  now  able  to  walk 
two  miles.  In  flexion  his  thigh  admits  of  consider- 
able motion,  but  he  cannot  extend  it  further  than 
to  bring  the  ham  to  the  plane  of  the  other  patella. 
The  knees  cannot  be  brought  together,  but  he  ad- 
vances one  before  the  other  in  the  attempt.  He 
can  sit  without  pain,  but  the  jolting  of  a  carriage 
hurts  him  exceedingly;  and  the  attempt  to  sit  on 
horseback  produces  excessive  suffering.  He  cannot 
straighten  his  leg  when  his  body  is  erect,  nor  can 
he  stoop  to  tie  his  shoe  on  the  injured  side.  Pain 
is  produced  by  resting  on  that  hip  in  bed.  No  at- 
tempt was  made  to  reduce  the  limb  ;  the  injury  to 
the  head  might  have  rendered  it  dangerous  in  the 
commencement,  and  at  the  time  when  I  saw  him 
there  was  no  chance  of  success. 


Dislocation  of  the  right  Femur  downwards,  or  into 
the  Foramen  Ovale. 

Sir: — Inclosed  is  the  case  of  dislocation  which 
you  requested  me  to  forward  to  you,  and  I  am  sor- 
ry it  has  not  been  in  my  power  to  put  you  in  pos- 
session of  it  before,  for  reasons  which  I  stated  when 
I  saw  you  last. 

I  am,  Sir, 

LeadenhaU  Street,  Your  obliged  servant, 

February  Mith,  1820.  J.  S.  Daniell. 


Case.  —  Mr  Thomas  Clarke,  a  farmer,  about  fifty 
years  of  age,  was  driving  home  in  his  cart  from 


PARTICULAR  DISLOCATIONS. 


85 


market,  when  the  horse  took  fright  and  ran  away 
with  him.  The  following  is  the  account  he  gives 
of  the  manner  in  which  the  accident  happened:  — 
in  his  endeavour  to  stop  the  horse,  he  fell  over  the 
front  of  the  cart  on  his  lace,  and  the  knee  struck 
against  some  part  of  it  in  the  act  of  falling,  by 
^by  which  means  the  thighs  were  separated;  the 
^heel,  he  also  states,  passed  over  his  hip.* 

My  friend,  Mr  Potter,  of  Ongar,  in  Essex,  whose 
ability  as  a  surgeon  in  that  neighbourhood  is  justly 
appreciated,  was  consulted  in  this  case,  between  two 
and  three  weeks  after  the  accident  had  happened  ; 
and,  as  I  was  visiting  him  at  the  time,  1  had  the 
pleasure  of  accompanying  him. 

The  nature  of  the  accident  was  extremely  evi- 
dent ;  the  limb  was  fully  three  inches  longer  than 
the  other,  the  body  bent  forwards,  the  knees  sepa- 
rated, and  the  foot  rather  inclined  outwards  ;  these 
were  the  leading  diagnostic  marks.  Mr  Potter,  hav- 
ing clearly  ascertained  the  position  of  the  dislocated 
limb,  I  accompanied  him  the  following  morning,  in 
order  to  assist  in  the  reduction;  and  the  following 
were  the  means  employed. 

Our  first  object  was  to  produce  relaxation  ;  and 
finding  the  patient  was  sufficiently  strong  to  bear  the 
plan  usually  recommended  in  cases  of  dislocation, 
where  much  resistance  is  expected,  we  drew  away 
some  blood  from  the  arm  ;  this,  however,  was  not 
sufficient  for  our  purpose,  and  a  solution  of  tartar 
emetic,  which  we  had  brought  with  us,  was  adminis- 
tered. The  patient  was  laid  upon  his  side,  close  to 
the  edge  of  the  bed  (that  being  the  most  convenient 
place),  a  girth  was  passed  round  the  pelvis,  and  car- 
ried through  the  frame  of  the  bedstead,  which  com- 


*  Q^uery.  —  Was  this,  or  the  extended  state  of  the  limbs,  the 
cause  of  the  dislocation  ?  A.  C, 


86 


PARTICULAR  DISLOCATIONS. 


pletely  prevented  the  possibility  of  the  body  moving 
whilst  extension  was  going  on ;  a  second  girth  was 
applied  between  the  thighs,  fixed  to  the  one  above, 
to  which  the  pulleys  were  attached.  Whilst  exten- 
sion was  making,  Mr  Potter  took  hold  of  the  limb  at 
the  knee,  and  drew  it  rather  upwards,  and  towards 
the  sound  thigh,  occasionally  rotating  the  limb. 
When  the  extension  had  been  continued  about  ter^ 
minutes,  the  nausea  produced  by  the  tartar  emetic 
was  so  excessive,  that  the  patient  begged  of  us  to 
desist  until  the  morrow,  observing,  he  felt  so  bad, 
that  he  was  fearful  of  falling  off  the  bed;  this  ex- 
clamation, it  hardly  need  be  said,  was  a  stimulus  to 
our  proceeding;  and  in  five  minutes  after,  the  limb 
was.  suddenly  heard  to  snap  into  its  original  cavity. 
The  patient  was  put  to  bed^  a  roller  being  applied 
round  the  pelvis,  and  at  the  end  of  five  days,  he  felt 
so  well  that  he  left  his  room  ;  and  at  the  expiration 
of  a  short  time,  suffered  no  other  inconvenience  than 
stiffness  in  the  joint. 

J.  S.  Daniell.* 


Mischief  from  improper  extension*  —  Although  a 
dislocation  into  the  foramen  ovale,  may  be  occasion- 
ally reduced  by  attempts  made  in  a  very  inappropri- 
ate direction,  yet  an  instance  has  occurred  which 
shows  the  mischief  that  may  arise  from  an  error  in 
this  respect. 

I  once  saw  the  following  case. 

Case. —  A  boy,  sixteen  years  old,  had  a  dislocation 
of  the  thigh  into  the  foramen  ovale  :  he  was  placed 

*  Mr  Daniell's  knowledge  of  his  profession,  and  his  zeal  in 
the  pursuit  of  it,  which  I  have  had  frequent  opportunities  of 
observing,  warrant  the  most  sanguine  hopes  of  his  success  in 
practice.  —  A.  C. 


PARTICULAR  DISLOCATIONS. 


87 


upon  his  sound  side,  and  an  extension  of  the  superior 
part  of  the  thigh  was  made  perpendicularly;  the 
surgeon  then  pressed  down  the  knee,  but  the  thigh 
being  at  that  moment  advanced,  the  head  of  the 
bone  was  thrown  backwards,  and  passed  into  the 
ischiatie  notch  ;  from  which  situation  it  could  not 
be  reduced. 

I  am  indebted  to  Mr  Key,  for  the  particulars  of 
the  annexed  case,  which  Avas  admitted  into  Guy's 
Hospital,  under  Mr  Forster. 

Dislocation  of  the  Thigh  into  the  Foramen  Ovale. 

Case, —  Stephen  Holmes,  aged  forty-one,  while 
working  in  a  gravel  pit,  at  Camberwell,  was  sudden^ 
ly  overwhelmed  by  a  large  mass  of  gravel,  and  re- 
mained buried  under  it,  till  dug  out  by  his  com- 
panions. When  the  gravel  was  removed,  he  was 
found  in  a  sitting  posture,  with  his  legs  widely  sepa- 
rated, and  unable  to  approximate  them.  In  this  po- 
sition he  was  brought  to  Guy's,  about  seven  o'clock 
in  the  evening,  an  hour  after  the  accident  had  hap- 
pened, and  was  placed  under  the  care  of  Mr  Carey, 
dresser  to  Mr  Forster. 

Being  undressed  and  placed  in  bed  in  the  recum- 
bent posture,  he  was  seen  lying  with  his  left  thigh 
bent  upon  the  pelvis,  his  knee  consequently  elevat- 
ed, and  the  whole  limb  fixed  at  a  considerable  dis- 
tance from  the  other.  On  carrying  the  eye  to  the 
upper  part  of  the  thigh  near  the  hip-joint,  a  consid- 
erable change  in  form  was  manifest ;  the  projec- 
tion of  the  trochanter  was  entirely  lost,  and  in  its 
place  a  deep  hollow  was  perceptible  ;  while,  at  the 
inner  part  of  the  thigh,  near  the  pubes,  a  distinct 
projection  appeared,  having  the  form  of  the  head 


88 


PARTICULAR  DISLOCATIONS. 


of  the  bone  covered  by  the  adductor  muscles.  From 
these  general  appearances,  we  regarded  the  acci- 
dent as  a  dislocation  of  the  femur  into  the  foramen 
ovale  of  the  pelvis,  and  proceeded  to  make  a  more 
minute  examination  of  the  limb,  to  ascertain  the 
precise  nature  of  the  injury. 

The  man  was  desired  to  rise  from  his  bed  and  sit 
on  the  edge  of  it,  which  he  did  without  incon- 
venience or  pain  ;  in  this  position  his  left  knee  pro- 
jected at  least  two  inches  and  a  half  beyond  the 
sound  limb ;  this  apparent  elongation  of  the  leg, 
arose  principally  from  the  oblique  bearing  of  the 
pelvis,  the  real  elongation  being  afterwards  ascer- 
tained to  be  not  more  than  an  inch  and  a  quarter. 
In  the  erect  posture,  which  he  maintained  with  some 
difficulty,  his  body  was  bent  forward  in  consequence  ' 
of  the  projection  of  the  pelvis  over  the  thigh  :  the 
knee  was  bent,  and  the  toe,  which  was  slightly  in- 
verted, rested  on  the  ground;  the  whole  limb  was 
advanced  before  the  sound  one,  and  remained  in  a 
state  of  abduction.  He  was  then  laid  upon  a  firm 
table  on  his  back,  and  the  capability  of  motion  in 
the  limb  was  carefully  noted.  His  knee  was  first 
bent  toward  his  breast  without  any  difficulty,  and  to 
as  full  an  extent  as  the  opposite  limb  ;  the  power  of 
abduction  was  also  complete,  and  the  attempt  was 
unattended  with  pain  ;  but  extension  and  adduction 
of  the  thigh  were  the  motions  most  impeded.  When 
the  limb  was  made  to  approximate  to  the  sound 
one,  which  could  not  be  done  without  producing 
pain  and  numbness  on  the  inner  side  of  the  thigh, 
the  patellae  remained  eleven  inches  distant  from 
each  other  ;  and  as  soon  as  the  hand  was  withdrawn 
from  the  ankle,  the  leg  flew  outward  with  a  spring 
from  the  reaction  of  the  two  small  glutaei.  The 
limb  could  not  be  carried  backward,  but  remained 
permanently  bent  at  the  hip-joint ;  and  when  any 
attempt  was  made  to  fix  it,  the  patient  complained 


PARTICULAR  DISLOCATIONS 


89 


of  great  pain  in  the  direction  of  the  psoas  and  ihacus 
muscles.  The  depression  observed  at  the  site  of  the 
trochanter  was  such  as  to  render  it  difficult  to  feel 
that  process;  while  on  the  inner  side  of  the  thigh, 
a  distinct  projection  was  formed  by  the  head  of  the 
bone,  which  could  be  felt  under  the  adductors. 
These  latter  muscles  were  rendered  very  tense  by 
the  projecting  bone.  The  nates  appeared  to  pre- 
serve their  usual  form. 

Reduction,  —  Having  never  had  an  opportunity  of 
witnessing  this  kind  of  dislocation  since  my  attendance 
at  the  hospitals,  during  the  last  eight  years,  I  wished 
to  see  how  far  the  method  of  reduction  which  you 
have  laid  down  was  applicable  in  the  present  case. 
Your  'Treatise  on  Dislocations  and  Fractures'  be- 
ing in  the  hands  of  one  of  the  students,  we  referred 
to  the  plate,  and  proceeded  to  apply  the  pulleys  and 
bandage  in  the  manner  there  delineated.  The  ap- 
paratus being  once  carefully  and  securely  adjusted, 
required  no  alteration,  as  it  neither  slipped  from  its 
situation,  nor  occasioned  any  inconvenience  to  the 
patient.  Extension  was  then  made  by  drawing  the 
displaced  limb  across  its  fellow,  while  the  pulleys 
drew  the  head  of  the  bone  outwards  :  but  in  doing 
this,  we  ran  some  risk  of  throwing  the  head  of  the 
femur  into  the  ischiatic  notch  ;  for  the  thigh  beins: 
large  and  fleshy  at  the  back  part,  was,  when  drawn 
across  the  other,  necessarily  carried  somewhat  for- 
ward, and  thus  tilted  the  head  of  the  bone  back- 
ward. Had  any  alteration  taken  place  in  the  situ- 
ation of  the  head  of  the  femur  durins:  this  exten- 
sion,  it  would  have  been  carried  under  the  acetabu- 
lum into  the  ischiatic  notch  ;  it  was  therefore  thought 
advisable  to  carry  the  leg  behind  the  sound  one; 
and  as  soon  as  this  was  done,  the  head  returned, 
with  an  audible  crack,  into  the  acetabulum.  The 
whole  extension  occupied  fifteen  minutes. 

12 


90 


PARTICULAR  DISLOCATIONS. 


This  species  of  dislocation  of  the  femur,  is  by 
far  the  most  easy  of  reduction  of  any  that  has  come 
under  my  observation;  and  it  may  be  presumed, 
that  had  the  leg  at  first  been  carried  behind  instead 
of  before  the  other,  the  replacement  of  the  limb 
might  have  been  effected  immediately.  Where  the 
limb  is  large  it  is  impossible  to  carry  it  in  a  right 
line  across  its  fellow  ;  and,  perhaps,  in  order  to 
avoid  the  danger  to  which  I  have  alluded,  and  which 
I  have  often  heard  you  point  out  in  your  lectures,  it 
would  be  as  well  to  adopt  the  line  of  extension  which 
in  this  instance  answered  so  Avell. 

October  15,  1822. — This  patient  could  stand  by 
the  side  of  his  bed  without  support  in  a  week  after 
the  accident. 

W.  A.  Key. 


DISLOCATION   BACKVTARDS,  OR  INTO  THE  ISCHIATIC  NOTCH. 

Anatomical  structure,  —  The  space  which  is  called 
the  ischiatic  notch  is  bounded  above  and  anteriorly 
by  the  ilium,  posteriorly  by  the  sacrum,  and  inferior- 
ly  by  the  sacro-sciatic  ligament.  It  is  formed  for  the 
purpose  of  giving  passage  to  the  pyriformis  muscle 
and  to  the  sciatic  nerve,  as  well  as  to  the  three  ar- 
teries, the  gluta3al,  the  ischiatic,  and  the  internal  pu- 
dendal. In  the  natural  position  of  the  pelvis,  it  is 
situated  posteriorly  to  the  acetabulum  and  a  little 
above  its  level.  When  the  head  of  the  bone  is 
thrown  into  this  space,  it  is  placed  backwards  and 
upwards,  with  respect  to  the  acetabulum  ;  therefore, 
although  I  call  this  the  dislocation  backwards,  it  is 
to  be  remembered  that  it  is  a  dislocation  backwards 
and  a  little  upwards. 

JYature  of  the  accident, —  In  this  dislocation  the 
head  of  the  thigh-bone  is  placed  on  the  pyriformis 


PARTICULAR  DISLOCATIONS.  91 

muscle,  between  ihe  edge  of  the  bone  which  forms 
the  upper  part  of  the  ischiatlc  notch,  and  the  sacro- 
sciatic  ligaments,  behind  the  acetabuham,  and  a  little 
above  the  level  of  the  middle  of  that  cavity. 

Detection  difficult. — ^  This  dislocation  is  the  most 
difficult  both  to  detect  and  to  reduce  :  to  detect, 
because  the  length  of  the  limb  differs  but  little,  and 
its  position,  in  regard  to  the  knee  and  foot,  is  not  so 
much  changed  as  in  the  dislocations  upwards:  to  re- 
duce, because  the  head  of  the  bone  is  placed  deep 
behind  the  acetabulum,  and  it  therefore  requires  to 
be  lifted  over  the  edge  of  that  cavity,  as  well  as  to 
be  drawn  towards  its  socket. 

Signs.  —  The  signs  of  this  dislocation  are,  that 
the  limb  is  from  half  an  inch  . to  one  inch  shorter 
than  the  other,  but  generally  not  more  than  half 
an  inch ;  that  the  trochanter  major  is  behind  its 
usual  place,  but  is  still  remaining  nearly  at  right 
angles  with  the  ilium,  with  a  slight  inclination  to^ 
wards  the  acetabulum.  The  head  of  the  bone  is 
so  buried  in  the  ischiatic  notch  that  it  cannot  be  dis'» 
tinctly  felt,  except  in  thin  persons,  and  then  only  by 
rolling  the  thigh-bone  forwards  as  far  as  the  compa- 
ratively  fixed  state  of  the  limb  will  allow.  The 
knee  and  foot  are  turned  inwards,  but  less  than  in 
the  dislocation  upwards  ;  and  the  toe  rests  against 
the  ball  of  the  great  toe  of  the  other  foot.  When 
the  patient  is  standing,  the  toe  touches  the  ground, 
but  the  heel  does  not  quite  reach  it.  The  knee  is 
not  so  much  advanced  as  in  the  dislocation  upwards, 
but  is  still  brought  a  little  more  forwards  than  the 
other,  and  is  slightly  bent.  The  limb  is  so  fixed 
that  flexion  and  rotation  are  in  a  great  degree  pre- 
vented. 

Dissection,  —  There  is  a  good  specimen  of  this 
accident  in  the  collection  at  St  Thomas's  Hospital, 
which  I  met  with  accidentally,  in  a  subject  brought 
for  dissection.    The  original  acetabulum  is  entirely 


92 


PARTICULAR  DISLOCATIONS. 


filled  with  a  ligamentous  substance,  so  that  the  head 
of  the  bone  could  not  have  been  returned  into  it. 
The  capsular  ligament  is  torn  from  its  connexion 
with  the  acetabulum,  at  its  anterior  and  posterior 
junction,  but  not  at  its  superior  and  inferior.  The 
Jigamentum  teres  is  broken,  and  an  inch  of  it  still 
adheres  to  the  head  of  the  bone.  The  head  of 
the  bone  rests  behind  the  acetabulum  on  the  pyri- 
formis  muscle,  at  the  edge  of  the  notch,  above  the 
sacro-sciatic  ligaments.  The  muscle  on  which  it 
rests  is  diminished,  but  there  has  been  no  attempt 
made  to  form  a  new  bony  socket  for  the  head  of 
the  OS  femoris.  Around  the  head  of  the  thigh- 
bone a  new  capsular  ligament  is  formed  ;  it  does 
not  adhere  to  the  articulatory  cartilage  of  the  ball 
of  the  bone  which  it  surrounds,  but  could,  when 
opened,  be  turned  back  to  the  neck  of  the  thigh- 
bone, so  as  to  leave  its  head  completely  exposed. 
Within  this  new  capsular  ligament,  which  is  formed 
of  the  surrounding  cellular  membrane,  the  broken 
ligamentum  teres  is  found.  (See  Plate,)  The  tro- 
chanter major  is  placed  rather  behind  the  acetabu- 
lum, but  inclined  towards  it  relatively  to  the  head  of 
the  bone. 

In  this  specimen,  from  the  appearance  of  the 
parts,  the  dislocation  must  have  existed  many  years  ; 
the  adhesions  were  too  strong  to  have  admitted  of 
any  reduction,  and  if  reduced,  the  bone  could  not 
have  remained  in  its  original  socket. 

Cause,  —  This  species  of  dislocation  is  produced 
by  the  application  of  force,  when  the  body  is  bent 
forward  upon  the  thigh,  or  when  the  thigh  is  bent 
at  right  angles  with  the  abdomen  ;  in  which  posi- 
tions, if  the  knee  be  pressed  inward,  the  head  of 
the  bone  is  thrown  behind  the  acetabulum. 

The  reduction  of  the  dislocation  in  the  ischiatic 
notch,  is,  in  general,  extremely  difficult,  and  is  best 


PARTICULAR  DISLOCATIONS. 


93 


effected  in  the  following  manner  :  the  patient  should 
be  laid  on  a  table  upon  his  side,  and  a  girth  should 
be  placed  between  the  pudendum  and  the  inner 
part  of  the  thigh,  to  fix  the  pelvis.  Then  a  wet- 
ted roller  is  to  be  applied  around  the  knee,  and 
the  leathern  strap  over  it.  A  napkin  is  to  be  car- 
ried under  the  upper  part  of  the  thigh.  The 
thigh-bone  is  then  to  be  brought  across  the  middle 
of  the  other  thigh,  measuring  from  the  pubes  to 
the  knee,  and  the  extension  is  to  be  made  with  the 
pulleys.  Whilst  this  is  in  progress,  an  assistant 
pulls  the  napkin  at  the  upper  part  of  the  thigh 
with  one  hand,  rests  the  other  upon  the  brim  of 
the  pelvis,  and  thus  lifts  the  bone,  as  it  is  drawn 
towards  the  acetabulum,  over  its  lip.  For  the  nap- 
kin I  have  seen  a  round  towel  very  conveniently 
substituted,  and  this  was  carried  under  the  upper 
part  of  the  thigh,  and  over  the  shoulders  of  an 
assistant,  who  then  rested  both  his  hands  on  the 
pelvis,  as  he  raised  his  body,  and  lifted  the  thigh. 
(See  Plate.) 

Although  the  preceding  is  the  method  in  which 
this  dislocation  is  most  easily  reduced,  yet  I  have 
seen  a  different  mode  practised;  and  I  shall  men- 
tion it  here,  as  it  shows  how  the  muscles  opposing 
the  pulleys,  will  draw  the  head  of  the  bone  to  its 
socket,  when  it  is  lifted  from  the  cavity  into  which 
it  has  fallen. 

Case, —A  man,  aged  twenty-five,  was  admitted 
into  Guy's  Hospital,  under  the  care  of  Mr  Lucas  ; 
upon  examination,  the  thigh  was  found  dislocated 
backwards;  the  limb  scarcely  differed  in  length 
from  the  other,  being  not  more  than  half  an  inch 
shorter ;  the  groin  appeared  depressed ;  the  tro- 
chanter was  resting  a  little  behind  the  acetabulum, 
but  inclined  upon  it  ;  the  knee  and  foot  w^ere  turn- 
ed inwards,  and  the  head  of  the  bone  could,  in  this 


94 


PARTICULAR  DISLOCATIONS. 


case,  be  felt  behind  the  acetabuhmi.  An  extension 
was  made  bj  pullejs  in  a  right  hne  with  the  body  ; 
at  the  saoie  time,  the  trochanter  major  was  thrust 
forward  with  the  hand,  and  the  bone  returned  in 
about  two  minutes  into  its  socket  with  a  violent 
snap. 

1  have  already  mentioned,  that  I  have  seen  no 
instance  of  a  dislocation  downwards  and  backicards  ; 
and  when  I  state,  that  I  have  been  an  attentive 
observer  of  the  practice  of  our  hospitals  for  thirty 
years,  was  also  for  many  years  in  the  habit  of 
daily  seeing  the  poor  of  London  at  my  house  early 
in  the  morning,  and  have  had  a  considerable  share 
of  private  practice,  I  may  be  allowed  to  observe, 
that  if  such  a  case  does  ever  occur,  it  must  be 
extremely  rare.  I  cannot  help  thinking,  also,  that 
some  anatomical  error  must  have  given  rise  to 
this  opinion,  as,  in  the  dislocation  downwards  and 
backwards,  the  head  of  the  bone  is  described  as 
being  received  still  into  the  ischiatic  notch;  but 
this  notch  is,  in  the  natural  position  of -the  pelvis, 
above  the  level  of  the  line  drawn  through  the 
middle  of  the  acetabulum  ;  and  hence  it  is,  that  the 
leg  becomes,  not  shorter,  but  longer,  when  the  bone 
is  dislocated  into  the  ischiatic  notch. 


Dislocation  of  the  right  Thigh  into  the  Ischiatic  JVotch, 

The  following  cast)  I  received  from  Mr  Rogers,  a 
very  intelligent  surgeon  at  Manningtree. 

Case.  —  Dear  Sir  :  — William  Dawson,  aged  thirty- 
four,  on  the  irnh  of  August,  1818,  while  spending 
his  harvest-home  with  several  of  his  companions, 
became  quarrelsome  with  one  of  them,  who  threw 
him  down,  and  trod  upon  him.  Upon  extricating 
himself,  and  endeavouring  to  rise,  he  found  some 


PARTICULAR  DISLOCATIONS. 


95 


serious  injury  to  his  right  thigh,  rendering  him  inca- 
pable of  standing;  in  this  state  he  was  dragged  by 
his  associates  tor  many  hundred  yards  into  a  stable, 
where  he  lay  till  the  next  morning.  I  then  saw  him 
lying  upon  a  mattress,  with  the  hip  and  thigh  on  the 
right  side  prodigiously  swollen  and  painful ;  and  I 
was  particularly  struck  with  the  appearances  of  the 
knee  and  foot  on  the  same  side,  which  w^ere  very- 
much  turned  inwards,  but  the  limb  was  scarcely 
shortened.  I  ordered  him  to  be  carefully  conveyed 
home  upon  a  shutter,  supported  by  six  men,  a  dis- 
tance of  about  half  a  mile.  From  the  immense 
swelling  and  general  enlaVgement  of  the  whole  of 
the  thigh,  and  of  the  soft  parts  around,  the  pelvis, 
it  was  impossible  to  ascertain  exactly  the  state  of 
the  injury  ;  but  it  was  fully  impressed  upon  my  mind, 
that  there  was  some  unusual  dislocation  of  the  head 
of  the  thigh-bone.  He  was  accordingly  ordered 
immediately  to  lose  blood,  both  by  general  and  to- 
pical means,  and  emollient  poultices  were  applied  to 
the  whole  of  the  swollen  parts ;  brisk  purgatives 
were  also  administered,  succeeded  by  saline  medi- 
cines, and  a  quiet  position  was  enjoined  for  eleven 
days,  by  w^hich  time  the  swelling  began  somewhat 
to  subside.  Still  the  precise  nature  of  the  injury 
was  not  satisfactorily  evident ;  but  it  w^as  thought  by 
Mr  Nunn,  of  Colchester,  and  Mr  Travis,  of  East 
Bergholt,  wdio  had  kindly  come  over  to  witness  it, 
that  there  was  a  luxation.  The  only  difficulty  we 
had  in  reconciling  this  notion  to  ourselves  was,  the 
belief  in  our  minds  that  no  author  had  adduced  an 
instance  of  this  accident,  without  an  alteration  in 
the  length  of  the  limb,  except  it  might  be  Mr  Astley 
Cooper,  in  his  new  publication,  which  neither  of  us 
had  yet  seen.  We  accordingly  had  recourse  to  a 
minute  examination  of  the  skeleton;  when  we  im- 
mediately fancied  we  could  account  for  the  absence 


96 


PARTICULAR  DISLOCATIONS. 


of  the  usual  marked  signs  of  displacement  of  the 
head  of  the  bone,  excepting  the  inversion  of  the 
knee  and  foot,  in  this  kind  of  luxation;  for  we 
noticed,  that  if  the  head  of  the  bone  be  luxated 
sideways  into  the  ischiatic  notch,  it  will  produce 
scarcely  any  difference  in  the  length  of  the  limb. 
Trusting  that  a  little  further  delay  might  not  be 
attended  with  any  material  disadvantage,  but  give  a 
chance  for  the  entire  subsidence  of  all  the  inflamma- 
tion and  swelling,  we  proposed  meeting  again  as  soon 
as  we  conveniently  could,  by  which  time  we  might 
consult  Mr  Cooper's  book.  We  accordingly  met 
on  Sunday,  the  30th  of  "August,  which  was  fifteen 
days  after  the  accident ;  and  from  the  complete  re- 
moval of  all  swelling,  the  whole  of  the  femoral  bone 
was  satisfactorily  traced  to  its  rounded  head,  which 
was  lodged  in  the  ischiatic  notch. 

Upon  referring  to  the  '  Essays,'  which  we  had 
now  before  us,  we  had  the  case  delineated  and  de- 
scribed ;  and  as  it  was  e-xhibited  in  a  plate,  we  had 
only  to  imitate,  in  order  to  accomplish  the  reduction 
of  the  bone.  In  the  presence  of  two  or  three  other 
medical  gentlemen,  who  had  now  joined  us,  we  com- 
menced the  operation;  and  as  it  would  be  unnecessa- 
ry to  state  every  particular,  considering  the  manner  in 
which  the  position  of  the  patient,  and  the  fixing  of 
the  pulleys  and  towels,  are  demonstrated  by  that 
publication,  suffice  it  for  me  to  remark,  that, 
after  ten  or  twelve  minutes  of  gradual  extension,  the 
reduction  of  the  bone  was  most  readily  and  admir- 
ably accomplished. 

Preparatory  to  commencing  the  operation,  we 
took  thirty  ounces  of  blood  from  the  arm  ad  deli- 
quium,  and  afterwards,  while  fixing  the  pulleys,  etc, 
we  gave  four  grains  of  tartarized  antimony,  at  inter- 
vals, to  produce  nausea.  Immediately  after  the 
operation,  we  gave  one  grain  of  opium,  applied  seda- 


PARTICULAR  DISLOCATIONS. 


97 


tive  lotions  to  the  parts,  and  proceeding  carefully 
for  about  a  fortnight,  the  patient  was  enabled  to 
move  upon  crutches,  and  was  shortly  after  sent  home 
perfectly  well. 

1  am  yours  respectfully, 

John  Rogers. 

Manningtree,  August  15th,  1818. 

The  relation  of  the  foregoing  case,  from  the  kind 
manner  in  which  Mr  Rogers  has  expressed  himself, 
may  savour  a  little  of  vanity;  but  I  shall  readily 
suffer  this  imputation,  and  shall  not  shrink  from 
avowing  the  satisfaction  which  I  feel,  whenever  my 
endeavours  have  in  any  degree  conduced  to  the 
advantage  of  my  professional  brethren,  or  to  the 
benefit  of  those  who  may  be  placed  under  their 
care. 

Incorrect  description  by  authors,  —  The  dislocation 
into  the  ischiatic  notch  has  been,  as  far  as  I  know,  in 
every  author  who  has  written  on  the  subject,  incor- 
rectly described;  for  it  has  been  stated,  that  the 
limb  was  lengthened  in  this  accident,  and  I  need 
scarcely  mention  the  mistakes  in  practice  which  have 
originated  in  so  erroneous  an  opinion  :  one  instance, 
however,  of  such  an  error  I  must  here  give.  A 
gentleman  wrote  to  me  from  the  country  in  these 
words:  —  'I  have  a  case  under  my  care  of  injury  to 
the  hip,  and  I  should  su|>pose  it  a  dislocation  into  the 
ischiatic  notch,  but  that  the  limb  is  shorter,  instead  of 
being  longer,  as  authors  state  it  to  be.'  Into  this  error 
those  authors  must  have  fallen  from  having  examined 
a  pelvis  separated  from  the  skeleton,  and  observed 
that  the  ischiatic  notch  was  below  the  level  of  the 
acetabulum  when  the  pelvis  was  horizontal,  although 
it  is  above  the  acetabulum  in  the  natural  oblique 
13 


98 


PARTICULAR  DISLOCATIOJSS. 


position  of  the  pelvis,  at  least,  as  regards  the  hori- 
zontal axis  of  the  two  cavities.  It  is  to  be  remem- 
bered, that  there  is  no  such  accident  as  a  dislocation 
of  the  hip  downwards  and  backwards. 

I  am  indebted  to  Mr  James  Chapman,  dresser  at 
Guy's  Hospital,  for  the  following  particulars. 

Case. — John  Cockburn,  a  strong  muscular  man, 
aged  thirty-three,  was  admitted  into  Guy's  Hospital 
on  the  31st  of  July,  IJilO.  While  carrying  a  bag  of 
sand,  at  Hastings,  on  the  24th  of  June,  he  slipped, 
and  dislocated  the  lei't  hi[)-joint ;  and  the  following 
is  the  account  he  gives  of  the  accident:  —  the  foot 
on  the  affected  side  was  plunged  suddenly  into  a 
hollow  in  the  road,  which  turned  his  knee  inwards 
at  the  same  time  that  his  body  fell  with  violence 
forwards.  On  the  day  on  which  the  accident  hap- 
pened, two  attempts  were  made  to  reduce  the  dislo- 
cation by  pulleys,  but  without  success;  and  on  the 
27th  of  June,  a  third,  but  equally  unsuccessful,  trial 
was  made,  although  continued  for  nearly  an  hour. 
He  was  directed  to  Guy's  Hospital  by  Mr  Stewart, 
surgeon  at  Hastings. 

It  w^as  found  upon  examination,  after  he  had  been 
admitted,  that  the  thigh  was  dislocated  backwards 
into  the  ischiatic  notch,  the  limb  was  a  little  short- 
ened, the  knee  and  foot  were  turned  inwards,  and 
the  toe  rested  on  the  ball  of  the  great  toe  of  the 
other  foot;  the  head  of  the  bone  could  not  be  felt; 
the  trochanter  major  was  opposite  the  acetabulum, 
the  rim  of  which  could  be  distinctly  perceived. 
When  the  body  was  fixed,  the  thigh  could  be  bent 
so  as  nearly  to  touch  the  abdomen.  The  patient 
was  carried  into  the  operating  theatre  soon  after  his 
admission;  and  when  two  pounds  of  blood  had  been 
taken  from  him,  and  he  had  been  nauseated  by  two 
grains  of  tartarized  antimony,  gradually  administer- 


PARTICULAR  DISLOCATIONS. 


99 


ed,  extension  was  made  with  the  pulleys  in  a  right 
line  with  the  body,  and  the  upper  part  of  the  thigh 
was  raised  wiiile  the  knee  was  depressed  ;  the  ex- 
tension was  continued  al  least  for  an  hour  and  a  half, 
during  which  time  he  took  two  grains  more  of  tar- 
tarized  antimony,  by  which  he  was  thoroughly  nause- 
ated ;  the  attempts,  however,  at  reduction  did  not 
succeed. 

On  the  third  of  August,  the  tenth  day  from  the 
accident,  Mr  Astley  Cooper  succeeded  in  reducing  it 
in  the  following  manner  ;  —  he  ordered  so  much 
blood  to  be  taken  from  the  arm  as  to  produce  a 
feeling  of  faintness.  A  table  was  placed  in  the 
centre,  between  two  staples,  upon  which  the  patient 
was  laid  on  his  right  side  ;  a  girth  was  passed  be- 
tween the  scrotum  and  the  thigh,  and  carried  over 
the  pelvis  to  the  &ta[)le  behind  hiijj  ;  and  thus  the 
pelvis  was,  as  far  as  possible,  fixed  ;  a  wetted  roller 
was  carried  around  the  lower  part  of  the  thigh, 
just  above  the  knee,  and  a  leathern  strap  buckled 
on  it,  to  which,  and  to  a  staple  before  the  limb,  the 
pulleys  were  fixed.  The  body  was  bent  at  right 
angles  with  the  thigh,  which  crossed  the  upper  part 
of  the  other  thigh;  then  the  extension  with  the 
pulleys  was  begun,  and  gradually  increased  until  it 
became  as  great  as  the  patient  could  bear.  An 
assistant  was  then  directed  to  get  upon  the  table, 
and  to  carry  a  strong  band  under  the  upper  part  of 
the  thigh,  by  which  he  lifted  it  from  the  pelvis,  so 
as  to  give  an  opportunity  for  the  head  of  the  bone 
to  be  turned  into  its  socket.  Mr  South,  who  held 
the  leg,  was  directed  to  rotate  the  limb  inwards,  and 
the  bone,  in  thirteen  minutes,  was  heard  to  snap 
suddenly  and  violently  into  its  socket. 

I  believe,  that  in  this  case,  I  should  not  have 
succeeded  in  reducing  the  limb,  but  from  attention 
to  two  circumstances :   first,  I  observed  that  the 


100 


PARTICULAR  DISLOCATIONS. 


pelvis  advanced  within  the  strap  which  was  employ- 
ed to  confine  it,  so  that  the  thigh  did  not  remain  at 
right  angles;  and  I  was  obh'ged  to  bend  the  body 
forward  to  preserve  the  right  angle  during  exten- 
sion ;  and,  secondly,  the  extension  might  have  been 
continued  for  any  length  of  time,  yet  the  limb 
would  never  have  been  reduced,  but  by  the  rotation 
of  the  head  of  the  thigh-bone  tow^ards  the  ace-- 
tabulum. 

Mr  Wickham,  jun.  of  Winchester,  has  had  the 
kindness  to  inform  me  of  a  case  of  this  dislocation 
which  had  been  admitted  into  the  Winchester 
Hospital,  under  the  care  of  Mr  Mayo,  one  of  the 
surgeons  of  that  institution,  w^ith  whose  permission 
the  following  circumstances  are  related. 

Winchester,  August  10th,  1819. 
Case.  —  John  Norgott,  aged  forty,  was  brought 
to  the  hospital  on  the  27th  of  December,  1817, 
from  the  neighbourhood  of  Alton,  with  an  injury  of 
the  hip;  twelve  days  had  elapsed  since  the  accident, 
Avithout  his  being  aware  of  the  nature  of  the  injury. 
He  reported  that  his  horse  had  fallen  with  him  and 
on  him,  so  that  one  leg  was  under  the  horse,  whilst 
his  body  was  in  a  half-bent  position,  leaning  against 
a  bank.  He  was  of  middle  stature,  but  very  mus- 
cular; the  leg  was  very  inconsiderably  shorter  than 
the  other,  and  but  little  advancing  over  it ;  in  fact, 
the  immobility  of  the  limb  was  the  chief  criterion 
of  the  dislocation ;  for  the  head  of  the  bone  was 
thrown  into  the  ischiatic  notch.  The  mode  of  re- 
duction was  simple  :  Mr  Mayo  had  the  limb  extend- 
ed by  the  pulleys,  so  as  to  bring  the  head  of  the 
bone  to  the  edge  of  the  acetabulum,  over  which  it 
was  then  tilted  by  a  towel,  fastened  round  the 


PARTICULAR  DISLOCATIONS. 


101 


patient's  thigh  and  the  neck  of  an  assistant.  The 
man  remained  three  or  four  weeks  before  he  was 
allowed  to  leave  the  house  ;  but  on  the  4th  of  Feb- 
ruary, he  was  discharged  cured. 

The  following  case  was  communicated  by  Mr 
Worts,  dresser  to  Mr  Chandler,  surgeon  to  St 
Thomas's  Hospital. 

Case.  —  James  Hodgson,  a  sailor,  aged  thirty-eight 
years,  a  strong  muscular  man,  was  admitted  into  St 
Thomas's  Hospital,  on  Tuesday,  the  18th  of  Feb- 
ruary, for  an  injury  which  he  had  received  in  his  left 
hip;  his  foot  having  been  raised  from  the  ground 
upon  a  chest  of  fruit,  when  another  fell  upon  his 
thigh,  striking  the  knee  inwards  ;  he  fell,  and  being 
taken  up  extremely  hurt,  he  was  directly  brought 
to  the  hospital.  Upon  examination,  I  conceived  that 
it  was  a  dislocation  of  the  hip-joint,  and  that  the 
head  of  the  bone  was  thrown  into  the  ischiatic 
notch.  Some  difference  of  opinion,  however,  arose 
upon  the  subject;  and  as  considerable  tension  exist- 
ed, which  prevented  the  head  of  the  bone  from 
being  distinctly  felt,  I  ordered  an  evaporating  lo- 
tion, and  left  the  case  for  further  inquiry.  On  re- 
flection, my  opinion  was  strengthened  concerning  the 
nature  of  the  injury,  as  it  was  clearly  pointed  out  by 
the  diminished  length  of  the  leg,  which  was  three 
quarters  of  an  inch  shorter  than  the  other,  and  by 
the  inversion  of  the  foot;  although  there  was  in  this 
case  more  power  of  flexion  in  the  limb  than  might 
have  been  expected,  but  no  rotation  outwards.  Mr 
Chandler  saw  the  case  on  Saturday  the  12th,  and, 
on  account  of  the  tension,  he  ordered  some  leeches 
to  be  applied  to  the  part,  and  the  lotion  to  be  con- 
tinued. Mr  Cline  saw  it  this  afternoon,  and  thought 
it  a  dislocation  in  the  ischiatic  notch. 


102 


PARTICULAR  DISLOCATIONS. 


Monday  morning,  the  14th.  The  swelhnghad  great- 
ly subsided,  and  I  thought  I  could  now  feel  the  head 
of  the  bone  on  rotation  of  the  limb.  Mr  Chandler 
saw  the  case  again  this  morning,  and  expressed  a  wish 
for  Mr  A.  Cooper  to  see  it.  Mr  Cooper,  at  my  re- 
quest, very  kindly  saw^  it  in  the  evening,  and  immedi- 
ately declared  it  to  be  a  dislocation  into  the  ischiatic 
notch;  and  upon  his  rotating  the  thigh,  I  could  much 
more  distinctly  than  before  feel  the  head  of  the  bone 
in  the  ischiatic  notch.  Mr  Cooper  recommended  me 
to  take  away  blood,  which  I  did  the  next  morning, 
to  the  amount  of  sixteen  ounces  ;  this  considerably 
relieved  the  pain  the  man  had  previously  suffered, 
and  the  tension  continued  to  abate  till  the  Saturday 
morning  following,  when  Mr  Chandler  again  saw  him, 
and  he  thought  it  had  sufficiently  subsided  to  justify 
the  attenx|rtat  reduction.  I  accordingly  made  prepar- 
ations in  the  following  manner: — at  about  half-past- 
two  o'clock,  I  took  sixteen  ounces  of  blood  from  the 
patient,  which  produced  no  sensible  effect ;  at  ten 
minutes  past  three,  I  took  about  twenty-seven  ounces 
more,  and  while  the  blood  was  flowing,  gave  him  a 
grain  of  emetic  tartar;  this  1  repeated  till  he  had 
taken  five  grains  at  intervals  of  a  few  minutes ;  and  as 
he  was  becoming  faint,  he  was  taken  into  the  thea- 
tre. I  applied  the  bandages  and  pulleys  to  the  pel- 
vis and  to  the  knee,  bringing  the  thigh  over  the  other ; 
we  kept  up  the  extension  about  ten  or  twelve  minutes 
before  we  used  the  strap  to  raise  the  head  of  the 
bone,  and  until  I  thought  it  had  made  some  progress 
towards  the  acetabulum.  We  then  continued  the 
extension,  gradually  increasing  it,  at  the  same  time 
endeavouring  to  raise  the  head  of  the  bone  and  turn- 
ing the  knee  outwards,  for  about  fifteen  minutes. 
I  had  now  lost  the  head  of  the  bone,  but  still,  as  it 
had  not  made  the  usual  noise  in  its  reduction,  I  thought 
that  it  would  be  wrong  to  jremove  the  pulleys,  as  the 


PARTICULAR  DISLOCATIONS. 


103 


action  of  the  muscles,  if  the  bone  had  not  been  reduc- 
ed, would  have  again  drawn  it  up,  in  which  opinion 
Mr  Martin,  who  assisted  me,  concurred.  The  man 
was  now  very  faint,  the  extension  was  therefore  con- 
tinued for  about  twenty-five  minutes  longer,  when 
the  strap  at  the  knee  getting  rather  loose,  we  remov- 
ed the  pulleys,  upon  which  it  was  found  that  the 
thigh  could  now  be  moved  in  any  direction,  and  that 
its  position  was  perfectly  natural.  The  bone  was 
replaced,  but  at  what  time  it  had  gained  its  situation 
no  one  could  judge,  neither  could  the  man  describe 
any  feeling  that  could  have  indicated  it ;  he  was  car- 
ried to  bed  in  a  very  faint  state. 

He  had  no  sickness  during  or  after  the  extension. 
1  gave  him  a  grain  and  a  half  of  opium  at  night, 
which  procured  rest. 

Sunday  morning.  —  He  had  some  pain  remaining, 
but  it  was  greatly  abated,  and  the  thigh  could  be 
moved  in  any  direction. 

Feb.  22,  1820.  W.  Worts. 

Mr  Worts  naturally  expresses  surprise  that  the 
bone  was  reduced  without  its  entering  the  acetabu- 
lum with  the  usual  iioise  ;  but  when  the  muscles  have 
been  some  time  contracted,  and  when  the  patient  is 
rendered  faint  by  bleeding,  and  by  the  nausea  of  tar- 
tarized  antimony,  they  do  not  act  with  the  same 
violence  as  in  the  first  few  hours  after  the  accident. 


toisLocATioN  ON  the  pubes. 

Cause,  —  This  dislocation  is  more  easy  of  detec- 
tion than  any  other  of  the  thigh.  It  happens  when  a 
person,  while  walking,  puts  his  foot  into  some  unex- 


104 


PARTICULAR  DISLOCATIONS. 


pected  hollow  in  the  ground;  and  his  body  at  the 
moment  being  bent  backwards,  the  head  of  the  bone 
is  thrown  forwards  upon  the  os  pubis.  A  gentle- 
man, who  had  met  with  this  dislocation  in  his  own 
person,  informed  me  that  it  happened  whilst  he  was 
walking  across  a  paved  yard  in  the  dark  :  he  did  not 
know  that  one  of  the  stones  had  been  taken  up,  and 
his  foot  suddenly  sunk  into  the  hollow,  and  he  fell 
backwards.  When  his  limb  was  examined,  the  head 
of  the  thigh-bone  was  found  upon  the  os  pubis. 

Symptoms,  —  In  this  species  of  dislocation  the 
limb  is  an  inch  shorter  than  the  other,  the  knee  and 
foot  are  turned  outwards,  and  cannot  be  rotated  in- 
wards, but  there  is  a  sh'ght  flexion  forwards,  and 
outward;  and  in  a  dislocation  which  had  been  long 
unreduced,  the  motion  of  the  knee  backwards  and 
forwards  was  full  twelve  inches ;  but  the  striking 
criterion  of  this  dislocation  is,  that  the  head  of  the 
thigh-bone  may  be  distinctly  felt  upon  the  pubes, 
above  the  level  of  Poupart's  ligament,  on  the  outer 
side  of  the  femoral  artery  and  vein  ;  and  it  feels  as 
a  hard  ball  there,  which  is  readily  perceived  to  move 
by  bending  the  thigh-bone. 

JVot  detected.  —  Although  this  dislocation  is  appa- 
rently easy  of  detection,  I  have  known  three  in- 
stances in  which  it  was  overlooked,  until  it  was  too 
late  for  reduction;  of  one,  there  is  a  preparation  at 
St  Thomas's  Hospital ;  another  occurred  to  a  gen- 
tleman from  the  country,  in  whom  it  was  not  dis- 
covered until  some  weeks  after  the  accident,  who 
then  submitted  to  an  extension  which  did  not  suc- 
ceed, and  came  to  London  to  ask  my  opinion,  when 
I  advised  him  against  a  further  attempt;  and,  in- 
deed, he  himself  was  disinclined  to  any  other  trial. 
The  third  was  a  patient  in  Guy's  Hospital,  who  was 
admitted  for  an  ulcerated  leg,  and  was  found  to  have 
a  dislocation  upon  the  pubes,  which  had  happened 


PARTICULAR  DISLOCATIONS. 


105 


some  years  before.  It  really  must  be  great  care- 
lessness which  leads  to  this  error,  as  the  case  is  so 
strikingly  marked. 

Dissection,  —  I  dissected  one  of  these  dislocations, 
and  we  have  it  preserved  in  our  anatomical  collec- 
tion. It  shows  changes  of  parts  nearly  equal  to 
those  of  the  dislocation  into  the  foramen  ovale.  The 
original  acetabulum  is  partly  filled  by  bone,  and 
partly  occupied  by  the  trochanter  major,  and  both 
are  much  altered  in  their  form.  The  capsular  li- 
gament is  extensively  lacerated,  and  the  ligamen- 
tum  teres  is  broken.  The  head  of  the  thigh-bone 
had  torn  up  Poupart's  ligament,  so  as  to  penetrate 
between  it  and  the  pubes.  The  head  and  neck  of 
the  bone  were  thrown  into  a  position  under  the  ilia- 
cut  internus  and  psoas  muscles  ;  the  tendons  of  which, 
in  passing  to  their  insertions  over  the  neck  of  the 
bone,  were  elevated  by  it,  and  put  on  the  stretch. 
The  crural  nerve  passed  on  the  fore  part  of  the 
neck  of  the  bone  upon  the  iliacus  internus  and  psoas 
muscles.  The  head  and  neck  of  the  thigh-bone 
were  flattened,  and  much  changed  in  their  form. 
Upon  the  pubes  a  new  acetabulum  is  formed  for  the 
neck  of  the  thigh-bone,  the  head  of  the  bone  being 
above  the  level  of  the  pubes.  The  new  acetabulum 
extends  upon  each  side  of  the  neck  of  the  bone,  so 
as  to  lock  it  laterally  upon  the  pubes.  {See  Plate.) 
Poupart's  ligament  confines  it  on  the  fore  part;  on 
the  inner  side  of  the  neck  of  the  bone  passed  the 
artery  and  vein,  so  that  the  head  of  the  bone  was 
seated  between  the  crural  sheath  and  the  anterior 
and  inferior  spinous  process  of  the  ilium. 

Distinguished fromjracture.  —  This  accident  might, 
by  an  inattentive  observer,  be  mistaken  for  a  fracture 
of  the  neck  of  the  thigh-bone;  but  the  head  of  the 
bone  felt  upon  the  pubes  will  decide  its  nature. 

Reduction,  —  In  the  reduction  of  this  dislocation, 
14 


106 


PARTICULAR  DISLOCATIONS. 


the  patient  is  to  be  placed  on  his  side  on  a  table;  -a 
girth  is  to  be  carried  between  the  pudendum  and  in- 
ner part  of  the  thigh,  and  fixed  in  a  staple  a  little 
before  the  line  of  the  body.  The  pulleys  are  fixed 
above  the  knee,  as  in  the  dislocation  upwards,  and 
then  the  extension  is  to  be  made  in  a  line  behind  the 
axis  of  the  body,  the  thigh-bone  being  drawn  back- 
wards. (^See  Plate,)  After  this  extension  has  been 
for  some  time  continued,  a  napkin  is  placed  under  the 
upper  part  of  the  thigh,  and  an  assistant,  pressing 
with  one  hand  on  the  pelvis,  lifts  the  head  of  the 
bone,  by  means  of  the  napkin,  over  the  pubes  and 
edge  of  the  acetabulum. 

The  following  case,  which  occurred  in  Guy's  Hos- 
pital, at  the  time  when  my  friend,  Mr  now  Dr  Gait- 
skill,  was  dresser  to  Mr  Forster,  will  best  exemplify 
the  mode  of  reduction.  He  was  a  dresser  in  the 
years  1803  and  1804. 

Bath,  August  1 3tK  1 8 1 7. 
Dear  Sir  :  —  The  report  of  the  case  of  dislocated 
thigh,  which  I  have  sent  you,  contains  every  material 
circumstance  within  my  recollection ;  it  will  afford 
me  much  pleasure  if  you  can  extract  from  it  any 
thing  useful  or  conducive  to  your  purpose. 

I  remain  your's  most  sincerely, 

Joseph  A.  Gaitskill. 

Case. —  A.  B.  with  a  dislocation  of  the  os  femoris 
upon  the  pubes,  was  admitted  into  Guy's  Hospital, 
under  Mr  Forster,  during  the  time  1  was  one  of  his 
dressers. 

The  length  of  the  limb  was  somewhat  diminished; 
the  foot  and  knee  were  turned  outwards  ;  but  the 
circumstance  which  more  clearly  evinced  the  nature 
of  the  accident  was,  that  the  head  of  the  thigh-bone 


PARTICULAR  DISLOCATIONS. 


107 


could  be  distinctly  perceived  under  the  integuments 
near  the  groin,  where  its  shape  could  be  ascertained, 
as  well  as  its  motion  felt,  when  the  thigh  was 
moved.  The  accident  had  happened  from  a  slip  or 
fall  he  had  sustained  about  three  hours  before. 

With  respect  to  the  reduction;  as  the  man  was 
brought  into  the  hospital  in  the  evening,  when  Mr 
Forster  was  absent,  I  considered  it  to  be  my  duty 
to  attempt  to  replace  the  bone  immediately.  I  there- 
fore ordered  the  patient  to  be  carried  into  the  op- 
erating theatre  ;  whilst  this  was  doing,  1  invited  my 
three  brother  dressers  into  the  surgery,  informed 
them  of  the  accident,  and,  to  avoid  confusion,  request- 
ed each  to  take  some  particular  part  in  the  process 
of  reduction.  The  patient  was  placed  on  his  sound 
side  on  a  table,  the  pulleys  were  applied  to  the 
thigh  in  the  usual  manner,  and  extension  was  begun 
in  a  straight  line,  with  the  design  of  raising  the  head 
of  the  bone  into  its  socket,  but  without  success. 
Reflecting  then  a  moment  on  the  mechanism  of  the 
bones,  and  their  new  relative  situation,  I  changed  the 
line  of  extension  to  a  little  backwards  and  down- 
wards, and  passing  a  towel  over  my  own  shoulders, 
and  under  the  superior  part  of  the  man's  thigh,  rais- 
ed it  by  extending  my  body. 

The  leg  being  kept  bent,  as  from  the  beginning  of 
the  operation,  nearly  to  a  right  angle  with  the  thigh, 
I  requested  one  of  the  dressers  to  take  hold  of  the 
ankle,  and  raise  it,  keeping  the  knee  at  the  same 
time  depressed,  by  which  means  the  thigh  was  turn- 
ed over  inwards,  and  in  a  very  short  time,  the  head 
of  the  bone  snapped  into  its  acetabulum. 

J.  A.  G. 


The  following  case  was  admitted  into  St  Thomases 
Hospital,  under  the  care  of  Mr  TyrrelK 


108  PARTICULAR  DISLOCATIONS. 


Guildhall,  Feb.  7th,  1823.  . 

My  dear  Sir:  —  I  take  this  opportunity  of  giving 
you  the  particulars  of  the  case  of  dislocation  on  the 
pubes,  which  you  wished  for. 

Case,  —  Charles  Pugh,  aged  fifty-five,  a  cooper, 
about  the  middle  size,  on  the  evening  of  the  23rd 
of  January,  during  the  time  he  was  making  water  at 
the  corner  of  a  street,  was  struck  on  the  back  part 
of  the  right  hip  by  the  wheel  of  a  cart ;  and  the 
blow  knocked  him  down.  He  w^as  taken  up  by 
some  persons  passing,  who,  finding  that  he  was  not 
able  to  walk,  took  him  to  St  Thomas's  Hospital. 
The  accident  happened  about  nine  o'clock  in  the 
evening,  and  I  was  sent  for  between  twelve  and  one 
o'clock,  when  I  found  a  dislocation  of  the  right  femur 
on  the  pubis,  the  particulars  of  which  were  as  follow. 

The  head  of  the  bone  could  be  distinctly  felt 
below  Poupart's  ligament,  immediately  on  the  outer 
side  of  the  femoral  vessels.  The  foot  and  knee 
were  turned  outwards,  with  very  little  alteration  in 
the  length  of  the  limb.  The  thigh  was  not  flexed 
towards  the  abdomen,  and  was  almost  immovable, 
admitting  only  of  partial  adduction  and  abduction. 
The  limb  could  be  rotated  outwards,  but  not  at 
all  inwards.  I  immediately  had  the  man  taken  into 
the  operating  theatre,  and  speedily  succeeded  in 
reducing  the  dislocation  by  the  following  means  :  — 
the  patient  was  placed  on  his  left  side,  a  broad  band 
was  passed  between  the  thighs,  and,  being  tied  over 
the  crista  of  the  ilium  on  the  right  side,  was  made 
fast  to  a  ring  fixed  in  the  wall.  A  wet  roller  hav- 
ing been  put  on  above  the  right  knee,  a  bandage 
was  buckled  over  it,  and  its  straps  attached  to  the 
hooks  of  the  pulleys,  by  which  a  gradual  extension 
was  made,  drawing  the  thigh  a  little  backwards  and 
downwards.    When  this  extension  had  been  kept 


PARTICULAR  DISLOCATIONS. 


109 


up  a  short  time,  I  directed  another  bandage  to  be 
appHed  round  the  upper  part  of  the  thigh,  close  to 
the  perineum,  by  means  of  which  the  head  of  the 
bone  was  raised,  and  in  the  course  of  a  few  minutes 
the  reduction  was  easily  accomplished.  The  pa- 
tient had  not  been  bled  or  taken  any  medicine,  he 
suffered  but  little  after  the  reduction,  and  was  able 
to  walk  without  pain  or  inconvenience  five  or  six 
days  afterw^ards.  On  the  day  following  the  accidejit, 
he  could  move  the  limb  freely  in  all  directions  with- 
out pain,  but  did  not  attempt  to  walk  until  the 
period  I  have  mentioned. 

If  I  have  omitted  any  points,  or  if  you  have  any 
wish  for  further  particulars,  a  message  or  a  note  by 
post  will  much  oblige, 

Your's  very  sincerely, 

Frederick  Tyrrell, 
Surgeon  to  St  Thomas's  Hospital 

m 

From  what  I  have  had  an  opportunity  of  observ- 
ing on  the  subject  of  dislocations,  I  believe  that  the 
relative  proportion  of  cases  will  be  in  twenty  as  fol- 
lows:—  twelve  on  the  dorsum  ilii ;  five  in  the  ischi- 
alic  notch  ;  two  in  the  foramen  ovale;  and  one  on 
the  pubes. 

The  cases  I  have  here  detailed,  with  the  dates  at 
which  they  were  presented,  manifest  the  frequent 
occurrence  of  this  accident  to  the  thigh.  How  it 
escaped  the  observation  of  surgeons  of  eminence  of 
former  times,  is  a  matter  of  surprise,  that  can  only 
be  accounted  for  by  the  difficulties  which  then  ex- 
isted in  the  pursuit  of  anatomy,  and  more  especially 
of  morbid  anatomy;  and  it  is  a  curious  circumstance, 
that  Mr  Sharpe,  formerly  surgeon  of  Guy's  Hospital, 
author  of  a  Treatise  on  Surgery,  and  in  many  re- 
spects an  excellent  surgeon,  who  had  a  large  share 


110 


PARTICULAR  DISLOCATIONS. 


of  the  practice  of  this  town,  did  not,  as  1  was  in- 
formed by  Mr  Cline,  beh'eve  that  a  dislocatiorj  of 
the  thigh-bone  ever  occurred. 

It  is  really  gratifying  to  observe  the  advancement 
of  knowledge  in  the  profession  at  the  present  period 
compared  with  that  of  fifty  years  ago.  What 
should  we  thmk  of  a  surgeon  in  the  metropolis  in  the 
present  day,  with  all  his  opportunities  of  seeing  dis- 
ease in  the  large  hospitals  of  this  city,  who  doubted 
the  existence  of  a  dislocation  of  the  thigh,  when  we 
find  that  our  provincial  surgeons  immediately  detect 
the  nature  of  these  injuries,  and  generally  succeed 
in  their  attempts  to  reduce  them?  Let  them  never 
forget,  however,  that  it  is  to  their  knowledge  of 
anatomy,  and,  more  especially,  of  morbid  anatomy, 
that  they  are  indebted  for  this  superiority. 

Mr  Charles  H.  Todd,  surgeon  to  the  Richmond 
Surgical  Hospital,  and  Professor  of  Anatomy  and 
Surgery  at  Dublin,  has  lately  published '  An  Account 
of  a  Dissection  of  the  Hip-joint  after  recent  Luxa- 
tion, with  Observations  on  the  Dislocations  of  the 
Femur  upwards  and  backwards;'  from  which  the 
fallowing  case  is  extracted. 

Case,  —  In  the  summer  of  1818,  a  robust  young 
man,  in  attempting  to  escape  from  his  bed-room  win- 
dow, in  the  second  floor  of  a  lofty  house,  fell  into  a 
flagged  area;  by  which  accident  his  cranium  was 
fractured,  and  his  left  thigh  dislocated  upwards  and 
backwards. 

The  dislocation  was  reduced  without  difficulty  ; 
however,  an  extensive  extravasation  of  blood  having 
taken  place  on  the  brain,  the  patient  lingered  in  a 
comatose  state  for  about  twenty-four  hours,  and  then 
died.  On  the  next  day,  dissection  was  performed, 
and  the  following  appearances  were  observed  in  the 
injured  joint  and  the  parts  contiguous  to  it. 


PARTICULAR  DISLOCATIONS. 


On  raising  the  gluteus  maximus,  a  large  cavity, 
filled  with  coagulated  blood,  was  found  between  that^i 
muscle  and  the  posterior  part  of  the  gluteus  medlus  : 
this  was  (he  situation  which  had  been  occupied  by 
the  dislocated  extremity  of  the  femur.  The  gluteus 
medius  and  minimus  were  uninjured.  The  pyriformis, 
gemini,  obturatores,  and  quadratus,  were  completely 
torn  across.  Some  fibres  of  the  pectinalis  were  also 
torn.  The  iliacus,  psoas,  and  adductores  were  un- 
injured. The  orbicular  ligament  was  entire  at  the 
superior  and  anterior  part  only,  and  it  was  irregularly 
lacerated  throughout  the  remainder  of  its  extent. 
The  interarticular  ligament  was  torn  out  of  the  de- 
pression on  the  head  of  the  femur,  as  in  Dr  Scott's 
case,  its  attachment  to  the  acetabulum  remaining 
perfect.    The  bones  had  not  sustained  any  injury. 

The  following  case,  which  has  recently  appear- 
ed in  one  of  the  Medical  Journals,  from  Mr  Cor- 
nish, surgeon  at  Falmouth,  I  have  thought  proper 
to  subjoin,  though  I  must  observe,  that  there  is 
reason  to  suspect  some  mistake  in  the  relation,  not 
of  the  narrator  of  the  case,  but  of  the  man  him- 
self; as  I  have  carefully  examined  the  books  of- 
both  hospitals  at  the  period  specified,  and  can  find 
no  such  name.  It  is,'  however,  possible  that  the 
patient  may  be  able  to  explain  the  difficulty;  but 
I  wish  Mr  Cornish  to  make  further  enquiries. 

Case, —  In  1812,  Mac  Fadder,  a  seaman,  about 
twenty  years  of  age,  in  coming  up  from  Green- 
wich to  London  on  the  outside  of  one  of  the  stages, 
fell  from  the  coach  and  injured  his  hip.  He  was 
carried  into  St  Thomas's  Hospital,  and  became  Mr 
Cline's  patient.  His  case  was  treated  as  fracture 
of  the  neck  of  the  thigh-bone.  Having,  after  the 
lapse  of  some  months,  experienced  no  relief  from 
the   means  that  were  adopted,  he  was  dismissed 


112 


PARTICULAR  DISLOCATIONS. 


with  the  assurance,  that  the  limb  would  be"  useless 
^  to  him  as  long  as  he  lived. 

The  man  was  subsequently  taken  into  Guy's  Hos- 
pital. Sir  A.  Cooper,  whose  patient  he  became, 
thought  that  the  head  of  the  femur  was  out  of  the 
socket ;  and  after  bleeding  him,  putting  him  into  the 
warm  bath,  and  admmistering  nauseating  doses  of 
tartrate  of  antimony,  endeavoured  to  reduce  the 
dislocation.  The  attempt  was  unsuccessful,  as  were 
also  others  that  were  afterwards  made,  and  he  was 
again  dismissed  as  an  incurable  cripple. 

In  1813,  about  twelve  months  after  the  accident, 
the  man  presented  himself  on  crutches  at  the  Fal- 
mouth Dispensary,  when  he  gave  me  the  foregoing 
history  of  his  case.  On  examining  him,  I  found 
the  injured  limb  about  two  inches  and  a  half  shorter 
than  the  other,  entirely  useless,  producing  great  pain 
on  bringing  it  to  the  ground,  and  the  knee  and  foot 
turned  inwards.  There  was  considerable  distortion 
about  the  joint ;  and  the  head  of  the  bone  appear- 
ed to  have  formed  a  bed  for  itself  among  the  mus- 
cles on  the  dorsum  ilii.  In  short,  he  had  every 
diagnostic  symptom  of  the  dislocation  upwards. 

In  consequence  of  the  duration  of  the  accident, 
and  the  failure  of  the  attempts  at  reduction  under 
the  management  of  Sir  A. 'Cooper,  I  considered 
his  case'  a  hopeless  one,  and  therefore  did  nothing 
for  him. 

In  March,  1818,  I  met  the  man  carrying  a  heavy 
basket  on  each  arm,  and  walking  without  the  slight- 
est degree  of  lameness.  Although  I  intimately 
knew  his  person,  having  seen  him  on  crutches 
about  the  town  for  two  or  three  years,  I  passed 
him,  hardly  believing  it  within  the  compass  of  pos- 
sibility, that  he  could  be  my  lame  patient;  but  af- 
ter having  walked  twenty  yards  or  more,  I  ran  back 
after  him  to  ascertain  the  fact.    On  satisfying  my- 


PARTICULAR  DISLOCATIONS. 


113 


self  of  his  identity,  of  which  1  entertained  such 
doubt,  and  on  enquiring  into  the  cause  of  his  cure, 
he  informed  me,  that  in  the  summer  of  1817,  Jive 
years  after  the  accident,  whilst  on  a  passage  from 
Falmouth  to  Plymouth,  in  a  little  coasting  vessel, 
*  the  ship  made  a  lurch,'  by  which  he  was  thrown 
out  of  his  birth.  At  the  moment  he  fell,  he  heard 
a  loud  crack  in  his  hip,  and  from  that  time  he  put 
aside  his  crutches,  and  recovered  the  perfect  use 
of  his  limb.  The  man  is  now  doing  duty,  as  an 
able  seaman,  on  board  a  ship  which  trades  from  this 
port  to  London. 

The  practical  importance  of  this  case  is  not,  per- 
haps, equal  to  the  curious  character  of  its  termina- 
tion. '  It  proves,'  says  Mr  Cornish,  '  the  possibility 
of  reducing  a  displaced  joint,  even  after  the  lapse  of 
years,  when  every  impediment  to  reduction  may  be 
fairly  supposed  to  exist  (particularly  the  oblitera- 
tion of  the  acetabulum),  and  when  most  surgeons 
would  judge  the  attempt  hopeless  ;  and  it  serves  to 
illustrate  the  proposition,  that  a  slight  effort,  when 
the  muscles  are  unprepared,  will  succeed  in  reduction 
of  dislocation,  after  violent  measures  have  failed."  '^ 

*  We  must  at  least  suppose  this  case  to  have  been  an  ex- 
ception to  a  very  general  rule,  as  we  find  in  very  short  lapses  of 
time,  compared  with  the  duration  of  this  dislocation  that  the 
cavity  of  the  joint  is  filled  up  and  almost  obliterated,  a  new 
socket  formed  for  the  bone,  and  the  muscles  altered  to  suit  the 
condition  caused  by  the  displacement.  Although  we  may  be 
led  by  the  event  to /iope — even  against  probability,  yet  there 
are  too  many  circumstances  unknown  in  regard  to  this  case,  to 
justify  us  in  drawing  any  general  conclusion.  J.  D.  G. 


15 


FRACTURES  OF  THE  OS  INNOMINATUM. 


Mistake,  —  As  these  accidents  are  liable  to  be 
mistaken  for  dislocations,  and  as  any  extension  made 
for  them  adds  extremely  to  the  patient's  sufferings, 
and  would  be  liable  to  produce  fatal  consequences  if 
there  existed  previously  a  probability  of  recovery, 
I  am  anxious  to  say  a  few  words  upon  them. 

Symptoms,  —  When  a  fracture  of  the  os  innomi- 
natum  happens  through  the  acetabulum,  the  head 
of  the  bone  is  drawn  upwards,  and  the  trochanter 
somewhat  forwards,  so  that  the  leg  is  shortened, 
and  the  knee  and  foot  are  turned  inwards  :  such  a 
case  may  be  readily  mistaken  for  dislocation  into  the 
ischiatic  notch.  If  the  os  innominatum  is  disjointed 
from  the  sacrum,  and  the  pubes  and  ischium  are 
broken,  the  limb  is  a  slight  degree  shorter  than  the 
other;  but  in  this  case  the  knee  and  foot  are  not 
turned  inwards,  but  outwards.  Of  the  first  of  these 
accidents  I  have  seen  two  examples,  of  the  latter 
only  one. 

Detection.  —  These  accidents  are  generally  to  be 
detected  by  a  perceptible  crepitus  on  the  motion  of 
the  thigh,  if  the  hand  be  placed  upon  the  crista  of 


FRACTURES  OF  THE  OS  INNOMINATUM.  115 


the  ilium;  and  they  are  attended  with  more  motion 
than  occurs  in  dislocations. 

With  respect  to  the  appearances  on  dissection, 
they  will  be  seen  in  plate  seven. 

Case.  —  A  man  was  brought  into  St  Thomas's 
Hospital,  in  January,  1791,  on  whom  a  hogshead  of 
sugar  had  fallen.  Upon  examination  the  right  leg 
was  found  about  two  inches  shorter  than  the  left, 
and  the  knee  and  foot  were  turned  inwards ;  these 
circumstances  induced  the  surgeon  under  whose  care 
he  fell  to  think  the  case  a  dislocation,  although,  as 
he  stated,  the  limb  appeared  to  be  more  moveable 
than  usually  happens  in  such  accidents,  and  there 
was  a  great  contusion  and  considerable  extravasation 
of  blood.  The  surgeon  used  the  utmost  caution  in 
making  a  very  slight  extension,  in  order  to  bring  the 
legs  to  an  equal  length,  in  which  he  did  not  succeed ; 
and  whilst  it  was  performing,  a  crepitus  was  dis- 
covered in  the  os  innominatum.  The  man  had  a  re- 
markable depression  of  strength,  and  paleness  of 
countenance,  and  appeared  to  be  sinking.  In  the 
evening  he  died. 

Upon  examination  of  the  body  the  following  ap- 
pearances were  observed:  —  The  posterior  part  of 
the  acetabulum  was  broken  off,  and  the  head  of  the 
thigh-bone  had  slipped  from  its  socket ;  the  tendon 
of  the  obturator  internus,  and  the  gemini,  tightly 
embraced,  the  neck  of  the  bone;  the  fracture  ex- 
tended from  the  acetabulum  across  the  os  innomina- 
tum to  the  pubes;  the  ossa  pubis  were  separated  at 
the  symphysis  nearly  an  inch  asunder,  and  a  portion 
of  the  cartilage  was  torn  from  the  right  pubes,  and 
adhered  to  that  on  the  left  side;  the  ilia  were  sepa- 
rated on  each  side,  and  the  pubes,  ischium,  and  ilium 
broken  on  the  left  side  ;  the  abdomen  contained  about 
a  pint  of  blood,  and  the  left  kidney  was  greatly 


116  FRACTURES  OF  THE  OS  INNOMINATUM. 


bruised  ;  the  integuments  were  stript  off  the  patella 
and  knee  on  one  side,  so  as  to  expose  the  capsular 
ligament. 

In  a  second  case  of  this  kind,  which  was  admitted 
into  St  Thomas's  Hospital,  having  the  appearance 
of  the  dislocation  backwards,  the  patient  lived  four 
days.  On  examination,  the  fracture  was  found  pass- 
ing through  the  acetabulum,  dividing  the  bone  into 
three  parts  ;  and  the  head  of  the  thigh-bone  was 
deeply  sunk  into  the  cavity  of  the  pelvis. 

The  following  case  of  fracture  and  dislocation  of 
the  bones  of  the  pelvis  lately  occurred  in  Guy's  Hos- 
pital :  I  am  obliged  for  the  particulars  to  Mr  Sand- 
ford,  who  attended  to  this  patient  as  dresser* 

Case,  —  Mary  Griffiths,  aged  thirty  years,  was 
admitted  into  Guy's  Hospital  at  five  o'clock  in  the 
afternoon  of  the  8th  of  August,  1817.  Her  pelvis 
had  sustained  a  severe  injury,  from  her  body  being 
pressed  by  the  wheel  of  a  cart  against  a  lamp-post. 

A  small  quantity  of  blood  had  been  taken  from  her 
arm  previous  to  her  admission ;  and  as  she  was  very 
pale,  her  pulse  extremely  weak,  and  her  faeces  pass- 
ed involuntarily,  no  more  blood  was  drawn* 

Soon  after  her  admission  she  was  examined  ;  when, 
by  placing  her  on  the  face,  with  one  of  my  hands  on 
the  back  of  the  right  ilium,  and  the  other  on  the 
pubes  of  the  same  side,  a  distinct  motion  and  crepitus 
could  be  perceived.  The  posterior  spine  of  the 
ilium  projected  upwards,  above  its  usual  junction 
with  the  sacrum,  and  it  was  thought  that  the  ilium 
was  dislocated  from  the  sacrum,  with  some  fracture, 
cither  of  the  ilium,  or  the  sacrum.  When  she  was 
turned  on  her  back,  and  examined  per  vaginam^  the 
pubes  were  found  passing  more  into  the  cavity  of 
the  pelvis  than  usual.  A  large  quantity  of  blood 
was  efTused  from  the  last  rib  to  the  upper  part  of 
the  thigh,  on  the  right  side. 


JF'RACTURES  of  the  OS  INNOMINATUM. 


117 


It  was  now  a  question  whether  this  extravasated 
blood  should  not  be  discharged  by  making  an  open- 
ing through  the  integuments,  as  it  appeared  to  be 
fluid;  but  upon  consideration,  it  was  thought  that 
the  vessels  would  still  bleed,  that  she  could  not  bear 
the  loss  of  blood  in  her  weakened  state,  and  that 
the  blood,  when  coagulated,  would  form  the  best 
security  against  further  effusion.  All  that  was  done, 
therefore,  was  to  roll  a  broad  bandage  round  the 
pelvis  to  fix  it  firmly,  to  give  tinct.  opii.  gt.  xxx.,  and 
to  draw  off  the  urine  from  her  bladder,  which  con- 
tained about  a  pint. 

In  the  evening,  the  extravasation  of  blood  was 
somewhat  increased,  and  she  complained  of  a  prick- 
ing sensation  in  the  right  thigh  and  leg,  which  in- 
duced her  to  loosen  the  bandage.  She  had  vomited; 
her  feet  were  cold;  she  had  severe  pain,  and  great 
thirst;  her  pulse  was  90,  and  small. 

On  the  9th,  she  complained  of  a  sensation  of  one 
side  tearing  from  the  other;  and,  upon  examination 
of  the  lower  extremities,  that  on  the  right  side  was 
found  shorter  than  the  other;  there  was  numbness 
also  on  that  side.  Her  tongue  was  furred,  but  her 
pain  and  thirst  somewhat  less ;  and  she  had  not 
the  same  coldness  in  her  feet  as  she  had  the  night 
previous. 

As  her  bowels  had  not  been  relieved  since  her 
admission,  aperient  medicine  wms  given  to  her;  and 
the  bladder  being  incapable  of  emptying  itself,  a 
catheter  was  employed.  The  ecchymosls  was  of 
great  extent,  and  it  was  doubtful  whether  it  could  be 
absorbed.  A  pillow  was  placed  against  the  right 
side  to  support  the  pelvis,  and  another  was  put 
under  the  knee,  to  preserve  the  limb  in  an  easy 
position. 

In  the  evening  of  this  day,  her  pulse  was  112. 
She  complained  of  much  pain  in  the  right  side  and 


118 


FRACTURES  OF  THE  OS  INNOMINATUM. 


groin.    The  catheter  was  again  obliged  to  be  used, 
and  aperient  medicines  to  be  repeated. 

On  the  morning  of  the  10th,  she  complained  that 
the  bones  of  the  pelvis  moved  upon  each  other, 
even  more  than  at  any  former  period,  and  that  she 
had  suffered  severe  pain ;  the  tongue  was  now  fur- 
red, her  pulse  fuller,  but  her  bowels  had  been  re- 
lieved, and  she  had  made  water  without  assistance. 
At  one  o'clock  this  day,  her  pulse  being  fuller,  and 
120  in  a  minute,  with  great  heat  of  skin,  I  bled  her 
to  the  amount  of  ten  ounces;  but  the  blood  did  not 
exhibit  any  signs  of  inflammation,  nor  did  the  loss  of 
blood  produce  any  apparent  effect  in  relieving  her 
symptoms. 

In  the  evening,  her  pain  and  fever  had  increased; 
and  as  she  complained  of  the  tightness  of  the  ban- 
dage which  still  surrounded  the  pelvis,  it  was  re- 
moved. The  catheter  was  again  obliged  to  be  em- 
ployed. Some  saline  medicine,  with  opium,  was  di- 
rected for  her. 

On  the  1 1th,  she  stated  that  she  had  passed  a  good 
night.  Her  pulse  was  120  and  softer;  her  tongue 
furred ;  she  was  directed  to  continue  her  medicines. 

A  stimulating  lotion  was  ordered  for  her  on  the 
12th,  to  produce  an  absorption  of  the  extravasated 
blood.  Some  spots  appeared  of  a  very  dark  colour, 
where  the  ecchymosis  had  been  most  severe,  and 
the  cuticle  was  abraded  upon  those  parts. 

On  the  13th,  her  report  was  more  favourable; 
her  bowels  were  open,  and  her  bladder  did  not  re- 
quire the  assistance  of  the  catheter.  However, 
she  still  complained  of  severe  pain  in  the  hip. 

14th.  As  the  excoriated  parts  seemed  disposed 
to  slough,  a  puncture  was  made  through  the  integu- 
ments, nearly  opposite  to  the  trochanter  major,  and 
a  quart  of  serum,  mixed  with  the  red  particles  of 
blood,  and  with  a  substance  which  appeared  adipose, 
was  discharged. 


FRACTURES  OF  THE  OS  INNOMINATUM.  1  1 9 


On  the  15th  the  fseces  and  urine  had  passed  into 
her  bed,  and  she  requested  to  be  removed  to  an- 
other; her  pulse  was  112.  The  puncture  made 
yesterday  does  not  seem  disposed  to  heal,  and  a  poul- 
tice was  directed  for  it. 

16th.  She  expressed  herself  relieved  by  her  re- 
moval into  another  bed  ;  her  pain  is  less  severe ; 
her  pulse  but  108.  She  was  now  directed  a  diet  to 
support  her  strength,  and  some  porter  was  given  her  ; 
but  on  the  17th,  as  she  had  been  observed  to  be 
slightly  delirious  the  preceding  night,  the  quantity  of 
porter  was  lessened. 

On  the  18th,  the  sloughing  of  the  part,  which  had 
been  excessively  bruised,  had  considerably  increased ; 
yet  her  tongue  was  cleaner,  and  her  skin  of  its 
natural  heat. 

On  the  following  day  she  appeared  better ;  had 
passed  a  good  night;  she  was  ordered  a  poultice  of 
stale  beer-grounds  to  the  hip ;  and  as  she  strongly 
requested  it,  she  was  turned  on  her  left  side,  as  her 
impression  was,  it  would  relieve  the  pain  she  felt  on 
the  right  side. 

The  sloughing  of  the  superior  and  posterior  part 
of  the  thigh  had  increased  upon  the  20th ;  and  she 
was  ordered  the  decoction  and  tincture  of  bark, 
with  saline  medicine  if  her  thirst  became  urgent; 
and  a  more  nutritious  diet. 

On  the  21st,  the  sloughing  had  increased;  the 
tongue  was  furred;  her  pulse  was  120.  On  the 
22nd  she  was  worse  ;  and  on  the  23rd,  her  stomach 
rejected  every  thing;  she  had  a  strong  impression 
that  she  could  not  recover;  she  refused  her  medi- 
cine, and  the  slough  had  increased.  In  the  evening 
of  the  24th,  she  died. 


120  FRACTURES  OF  THE  OS  INNOMINATUM. 


Examination, 

On  the  25tb,  the  body  was  examined.  —  A  frac- 
ture was  found  passing  through  the  body  of  the 
pubes  on  the  left  side,  and  through  the  ramus  of  the 
left  ischium. 

The  right  os  innominatum  was  separated  from  the 
sacrum  at  the  sacro-iliac  symphysis,  and  a  part  of 
the  transverse  processes  of  the  sacrum  were  broken 
off,  and  torn  from  the  sacrum  with  the  ligaments. 
The  cartilage  and  ligaments  of  the  symphysis  pubis 
were  torn,  and  the  left  sacro-iliac  symphysis  had 
given  way ;  the  ligament  over  it  being  torn,  and  the 
bones  separated  sufficiently  to  admit  of  the  handle 
of  a  scalpel  being  received  between  them.  (See 
Plate.) 

Blood  was  found  extravasated  in  the  pelvis,  be- 
hind the  peritonaeum. 

Jonathan  Sandford, 

I  have  known  three  instances  of  recovery  from 
simple  fracture  of  the  os  innominatum  :  two  of  these 
were  fractures  of  the  ilium,  and  the  nature  of  the 
accident  was  easily  detected  by  the  crepitus  which 
was  perceived  upon  moving  the  crysta  of  the  ilium  5 
the  third  case  was  a  fracture  at  the  junction  of  the 
ramus  of  the  ischium  and  pubes.  In  the  two  first 
a  circular  roller  was  applied  upon  the  pelvis, 
and  the  patient  was  freely  bled ;  but  in  the  latter 
no  bandage  was  employed.  I  have  also  known  a 
compound  fracture  of  the  os  innominatum  recover ; 
but  Mr  Hulbert,  surgeon,  sent  me  a  compound  frac- 
ture of  the  ilium,  which  had  proved  fatal. 

Several  cases  have  also  occurred  within  my 
knowledge  of  fracture  of  the  pubes,  near  its  sym- 


FRACTURES  OF  THE  OS  INNOMlNATUM.  121 

physis,  accompanied  with  laceration  of  the  bladder, 
each  of  which  proved  destructive  ;  but  when  the 
bones  have  been  broken  without  injury  to  the  blad- 
der, the  patients  have  recovered.*  The  bladder  is 
burst  or  not,  in  this  accident,  according  to  its  state 
of  distension  or  emptiness  at  the  moment  of  the 
accident ;  for,  if  empty,  it  escapes  injury. 

*  There  is  at  this  time  (Sept.  1823),  a  case  in  Guy's  Hospit- 
al, in  which  the  bladder  is  believed  to  be  ruptured  below  the 
reflexion  of  the  peritonaeum,  and  between  it  and  the  pubes, 
and  the  man  appears  to  be  recovering  by  wearing  a  catheter. 
But  in  cases  where  the  injury  is  above  the  line  of  reflexion  of 
the  peritonaeum,  the  urine  escapes  into  the  cavity  of  the  abdo- 
men, and  excites  general  inflammation. 


16 


FRACTURES  OF  THE  UPPER  PART 
OF  THE  THIGH-BONE. 


Before  1  enter  into  a  description  of  the  disloca- 
tions of  other  joints,  it  will  be  proper  to  point  out 
the  fractures  incident  to  the  upper  part  of  the 
thigh-bone,  as  it  is  essentially  necessary  that  these 
accidents  should  not  be  confounded  with  dislocations, 
or  with  each  other,  a  mistake  which  has  but  too 
frequently  happened.  Indeed,  it  must  be  confessed, 
that  their  discriminating  marks  are  sometimes  with 
difficulty  detected,  and  that  the  different  species  of 
fracture  are  likewise  frequently  confounded;  for 
three  distinct  species,  very  different  in  their  nature 
and  in  their  result,  have  been  described  and  classed 
under  the  indiscriminate  appellation  of  fracture  of 
the  neck  of  the  thigh  bone.  Hence  has  arisen  that 
difference  of  opinion,  which  has  led  to  much  dis- 
cussion respecting  the  processes  which  nature  em- 
ploys for  their  cure,  and  which  less  hypothetical 
reasoning,  and  more  attention  to  the  development 
of  such  accidents  by  dissection,  would  have  been 
the  means  of  preventing.  Whilst  one  surgeon  as- 
serts that  all  attempts  to  cure  them  are  unavailing, 


FRACTURES  OF  UPPER  PART  OP  THIGH-BONE.  123 


another  maintains  that  they  admit  of  union  like 
fractures  of  other  bones ;  which  latter  opinion  is 
only  true  as  far  as  regards  two  species  of  these 
fractures. 

I  shall  now,  therefore,  proceed  to  state  the  results 
of  my  observations  in  living  persons  who  have  been 
the  subjects  of  these  accidents  ;  of  my  examination 
of  the  dead  body;  and  of  some  experiments  upon  in- 
ferior animals,  which  illustrate  this  subject. 

These  accidents  are  more  frequent  than  disloca- 
tions of  the  thigh-bone  ;  for,  whilst  there  are  receiv- 
ed into  the  hospitals  of  Guy's  and  St  Thomas's  (con- 
taining about  nine  hundred  persons),  not  more  upon 
an  average  than  two  such  dislocations  in  a  year,  the 
wards  are  seldom  without  an  example  of  fracture 
of  the  upper  part  of  the  thigh-bone. 

Different  species  of  Fracture  of  the  Upper  Part  of  the 
Thigh-Bone, 

.  These  are,  as  we  have  already  observed,  three  in 
number. 

First :  That  in  which  the  fracture  happens  through 
the  neck  of  the  bone  entirely  within  the  capsular 
ligament. 

Secondly :  A  fracture  external  to  the  ligament, 
through  the  neck  of  the  thigh-bone  at  its  junction 
with  the  trochanter  major;  by  which  the  trochanter 
is  split,  and  the  neck  of  the  thigh-bone  is  received 
into  its  cancelli. 

Thirdly  :  A  fracture  through  the  trochanter  ma- 
jor, beyond  its  junction  with  the  cervix  femoris. 


124 


FRACTURES   OP  THE  UPPER  PART 


FRACTURES  OP  THE  NECK   OF  THE   THIGH-BONE,  WITHIN 
THE  CAPSULAR  LIGAMENT. 

Appearances  ;  difference  in  length,  "  The  appear* 
ances  which  are  produced  by  this  fracture  are  as 
follow  :  —  the  leg  becoQies  from  one  to  two  inches 
shorter  than  the  other  5  for  the  connexion  of  the 
trochanter  major  with  the  head  of  the  bone,by 
means  of  the  cervix,  being  destroyed  by  the  frac- 
ture, the  trochanter  is  drawn  up  by  the  muscles  as 
high  as  the  ligament  will  permit,  and  consequently 
rests  upon  the  edge  of  the  acetabulum,  and  upon 
the  ilium  above  it.  The  difference  in  the  length  of 
the  limbs  is  best  observed  by  desiring  the  patient 
to  place  himself  in  the  recumbent  posture  on  his 
back,  when,  by  comparing  the  malleoli,  it  will  be 
generally  found  that  one  leg  is  shorter  than  the  other. 
The  usual  state  of  the  limb  is,  that  the  heel  on  the 
injured  side  rests  in  the  hollow  between  the  malleo- 
lus internus  and  tendo  Achillis  of  the  other  leg ;  but 
there  is  some  variety  in  this  respect ;  a  fork  is  some- 
times formed  in  the  trochanter  minor,  which  catches 
the  neck  of  the  bone,  and  prevents  a  greater  ascent 
than  half  an  inch.  (^See  Plate.')  Mr  Brodie  informed 
me  that  he  dissected  a  case  in  which  the  cervix  was 
obliquely  broken,  and  in  which  the  upper  part  of  the 
bone  prevented  the  ascent  of  the  lower.  On  the 
other  hand,  when  the  fracture  has  happened  for 
a  length  of  time,  and  the  patient  has  borne  upon  the 
injured  limb,  the  ligament  becomes  extended,  and 
the  leg  is  shortened  four  inches ;  of  this  Mr  Lang- 
staff  mentioned  to  me  an  instance  in  a  man  of  the 
name  of  Campbell,  aged  eighty-two,  in  whom  the 
heel  was  obliged  to  be  elevated  four  inches  to 
make  the  bearing  of  the  limbs  equal.    1  saw  the 


OF  THE  THIGH-BONE. 


125 


fractured  parts  in  this  man,  and  the  shoe  he  wore, 
which  entirely  verified  Mr  L's  statement.  The 
retraction  is  at  first  easily  removed  by  drawing  down 
the  shortened  limb,  when  it  will  appear  of  the  same 
length  with  the  other  ;  but  immediately  this  extension 
is  abandoned,  and  the  patient  exerts  himself,  the 
muscles  draw  it  into  its  former  position;  and  this 
appearance  maybe  repeatedly  produced  by  extending 
the  limb.  This  evidence  of  the  nature  of  the  accident 
continues  until  the  muscles  acquire  a  fixed  contrac- 
tion, which  enables  them  to  resist  an  extension  which 
is  not  of  a  powerful  kind. 

Foot  turned  outward.  —  Another  circumstance 
which  marks  the  nature  of  this  injury  is,  the  ever- 
sion  of  the  foot  and  knee ;  and  this  state  depends 
upon  the  numerous  and  strong  external  rotatory 
muscles  of  the  hip-joint,  which  proceed  from  the 
pelvis  to  be  inserted  into  the  thigh-bone,  and  to 
which  very  feeble  antagonists  are  provided:  the  ob- 
turatores,  the  pyriformis,  the  gemini  and  quadratus, 
the  pectinalis  and  triceps,  all  assist  in  rolling  the 
thigh-bone  outwards;  whilst  a  part  of  the  glutasus 
medius  and  minimus,  and  the  tensor  vaginae  femoris, 
are  the  principal  agents  of  rotation  inwards.  It  has 
been  denied  that  this  eversion  is  caused  by  the  mus- 
cles, and  it  has  been  attributed  to  the  mere  weight 
of  the  limb;  but  any  one  may  satisfy  himself  that  it 
arises  chiefly  from  the  muscles,  by  feeling  the  re- 
sistance which  is  made  to  any  attempt  at  rotation  of 
the  thigh  inwards.^    This  difficulty  is  also  in  some 

*  In  the  sound  state  of  the  limb,  when  we  rest  it  on  a  plane, 
the  body  being  recumbent,  and  allow  the  muscles  to  relax,  it 
Invariably  falls  to  the  outside.  The  weight  of  the  foot  acting 
on  so  long  a  lever  is  sufficient  to  effect  this.  The  thigh  being 
shortened  '  one  or  two  inches,'  it  is  not  difficult  to  understand 
how  the  psoas,  ihacus  and  pectinaeus  may  fix  it  against  the  ilium. 


126  FRACTURES  OP  THE  UPPER  PART 


measure  attributable  to  the  length  of  the  cervix  fe- 
moris,  which  remains  attached  to  the  trochanter 
major;  because  in  proportion  to  its  length,  by  rest- 
ing against  the  ilium,  the  trochanter  is  prevented 
from  turning  forwards. 

Directly  that  the  bed-clothes  are  removed,  two 
circumstances  strongly  arrest  the  attention  of  the 
surgeon  :  namely,  the  diminished  length  of  the  in- 
jured limb,  and  the  eversion  of  the  foot  and  knee. 
In  the  dislocation  upwards,  the  head  and  neck  of 
the  bone  prevent  the  trochanter  from  being  drawn 
backwards,  whilst  the  broken  and  shortened  neck 
of  the  thigh-bone,  in  fracture  of  this  part,  readily 
admits  it ;  and  hence  the  reason  that  the  foot  is  in- 
verted in  luxation,  and  everted  in  fracture.  It  is, 
hovv'ever,  proper  to  state,  that  an  exception  to  this 
rule  does  now  and  then  exist,  and  that  the  limb  is 
found  inverted  ;  but  it  is  of  extremely  rare  occur- 
rence. Several  hours  must  elapse  before  this  ever- 
sion assumes  its  most  decisive  character,  as  the  mus- 
cles require  some  time  to  assume  a  determined  con- 
traction; and  this  is  the  reason  why  the  injury  has 
been  mistaken  for  dislocation  on  the  dorsum  ilii. 
The  surgeon  having  been  called  soon  after  the  acci- 
dent has  happened,  before  the  muscles  had  acquired 
that  state  of  contraction  to  which  they  are  liable, 
has  been  led  to  mistake  the  nature  of  the  injury, 
because  the  foot  is  not  so  decidedly  everted  as  it 
afterwards  becomes;  and  for  this  reason  patients, 
even  in  hospital  practice,  have  been  exposed  to  use- 
less and  painful  extensions. 

Degree  of  pain.  —  In  fractures  of  the  neck  of  the 
bone  within  the  ligament,  the  patient,  when  per- 


and  together  with  the  external  muscles  prevent  the  rotation  in- 
wards, although  this  position  is  originally  produced  by  the 
gravity  of  the  limb.  J.  D.  G. 


OP  THE  THIGH-BONE. 


127 


fectly  at  rest  in  the  horizontal  posture,  suffers  but 
little  ;  but  any  attempt  at  rotation  is  attended  with 
some  pain,  because  the  broken  extremity  of  the 
bone  then  rubs  against  the  inner  surface  of  the  cap- 
sular ligament,  upon  Avhich  it  is  drawn  by  the  action 
of  the  muscles.  The  pain  is  felt  in  this  accident  in 
the  upper  and  inner  part  of  the  thigh,  opposite  to 
the  insertion  of  the  iliacus  and  psoas  muscles  into 
the  trochanter  minor,  or  sometimes  just  below  this 
point. 

Degree  of  motion,  —  The  perfect  extension  of  the 
thigh  may  be  easily  effected,  but  flexion  is  more  diffi- 
cult, and  somewhat  painful ;  and  its  degree  depends 
upon  the  direction  in  which  the  limb  is  bent;  if  the 
flexion  be  outwards,  it  is  accomplished  with  but  lit- 
tle comparative  suffering  ;  but  if  the  thigh  be  direct- 
ed towards  the  pubes,  the  act  of  bending  the  limb 
is  with  difficulty  accomplished,  and  is  attended  with 
greater  pain ;  for  the  movement  is  easier  or  more 
difficult,  in  proportion  as  the  neck  of  the  bone  is 
shorter  or  longer. 

Situation  of  the  trochanter  major,  —  In  this  acci- 
dent the  trochanter  major  is  drawn  up  towards  the 
ilium,  but  the  broken  neck  of  the  bone  attached  to 
the  trochanter  is  placed  nearer  the  spine  of  the  ili- 
um than  the  trochanter  itself,  in  which  situation  it 
afterwards  remains;  and  this  alteration  of  position 
makes  the  trochanter  project  less  on  the  injured 
side,  because  it  is  no  longer  supported  by  the  neck 
of  the  bone,  as  in  its  natural  state,  but  rests  in  close 
apposition  with  the  edge  of  the  acetabulum,  and  is, 
consequently,  much  more  concealed  than  usual,  until 
the  muscles  waste  from  the  duration  of  the  injury, 
when  the  trochanter  can  bo  distinctly  felt  upon  the 
dorsum  ilii;  but  there  will  be  a  greater  or  less  pro- 


128 


FRACTURES  OF  THE  UPPER  PART 


jection  according  to  the  length  of  the  fractured 
cervix  attached. 

Jlppearance  in  the  erect  position*  —  If  doubt  exist 
of  the  nature  of  the  accident,  let  the  patient  be  di- 
rected to  stand  by  his  bed-side,  supported  by  an 
assistant,  and  to  bear  his  weight  upon  the  sound  limb  ; 
the  surgeon  then  observes  the  shortened  state  of  the 
injured  leg  ;  the  toes  rest  upon  the  ground,  but  the 
heel  does  not  reach  it ;  the  knee  and  foot  are  evert- 
ed;  and  the  prominence  of  the  hip  is  diminished. 
The  least  attempt  to  bear  upon  the  injured  limb  is 
productive  of  pain,  which  seems  to  be  occasioned  by 
the  tension  of  the  psoas,  iliacus,  and  obturator  exter- 
nus  muscles,  in  the  attempt,  as  well  as  by  the  pres- 
sure of  the  broken  neck  of  the  bone  against  the  in- 
terior surface  of  the  capsular  ligament. 

Crepitus,  —  A  crepitus  like  that  which  accompa- 
nies other  fractures  might  be  expected  to  occur  in 
this  accident,  but  it  is  not  discoverable  when  the  pa- 
tient rests  on  his  back  with  the  limb  shortened;  if, 
however,  the  leg  be  drawn  down,  so  as  to  bring  the 
limbs  to  the  same  length,  and  rotation  be  then  per- 
formed, the  crepitus  will  be  observed,  as  the  broken 
ends  of  the  bone  are  thus  brought  into  contact;  but 
the  rotation  inwards  most  easily  detects  the  fracture. 
When  the  patient  is  standing  on  the  sound  leg,  with 
the  fractured  limb  unsupported,  by  rotating  it  inwards, 
the  crepitus  will  sometimes  be  perceived,  as  the 
weight  of  the  limb  brings  the  broken  bones  nearer 
in  apposition. 

More  frequent  in  ivomen.  —  Women  are  much 
more  liable  to  this  species  of  fracture  than  men  :  we 
rarely  in  our  hospitals  observe  it  in  the  latter,  but 
our  wards  are  seldom  without  an  example  of  it  in  the 
aged  female.  The  more  horizontal  position  of  the 
neck  of  the  bone,  and  the  comparative  feebleness  of 


OF  THE  THIGH-BONE^ 


129 


the  female  constitution,  are  the  probable  reasons  of 
this  peculiarity.'^ 

To  the  circumstances  I  have  already  mentionedj 
as  strongly  characterizing  this  accident,  must  be  add- 
ed the  period  of  life  at  which  it  usually  occurs;  for 
the  fracture  of  the  neck  of  the  thigh-bone  within 
the  capsular  ligament,  seldom  happens  but  at  an 
advanced  period  of  life,  whilst  the  other  fractures 
which  I  have  to  describe  happen  at  all  periods  :  and 
hence  has  arisen  the  great  confusion  with  respect  to 
the  nature  of  this  injury;  for  we  find  that  surgeons 
of  the  highest  character  have  confounded  fractures 
external  to  the  capsular  ligament  with  those  which 
are  within  the  articulation  ;  and  mention  the  latter 
as  occurring  at  a  period  of  life  in  which  they  scarcely 
ever  happen.f  It  has  been  also  said,  that  in  early 
life  these  boneS  will  readily  unite  ;  an  assertion 
which  I  notice  only  to  show  the  confusion  which  has 
arisen  on  this  subject. 

Changes  in  age  in  the  bones,  — Old  age,  how- 
ever, is  a  very  indefinite  term  ;  for  in  some  it  is  as 
strongly  marked  at  sixty,  as  in  others  at  eighty 
years.  That  regular  decay  of  nature  which  is  call- 
ed old  age,  is  attended  with  changes  which  are 
easily  detected  in  the  dead  body  ;  and  one  of  the  prin- 
cipal of  these  is  found  in  the  bones,  for  they  become 
thin  in  their  shell,  and  spongy  in  their  texture. 
The  process  of  absorption  and  deposition  varies  at 
different  periods  of  life  ;  in  youth  the  arteries,  which 

-  *  The  greater  width  of  the  pelvis  in  women,  and  the  distance 
to  which  the  upper  part  of  the  thigh-bones  are  thereby  remov- 
ed from  each  other,  as  it  throws  the  feet  nearer  to  the  central 
line  of  the  body,  must  render  the  neck  of  the  thigh-bone  in  them, 
much  more  liable  to  fracture  from  shocks  received  on  the  feet, 
than  in  men.  The  force  in  this  case  is  exerted  immediately  on 
the  neck  of  the  bone,  while  in  a  man  it  would  be  chiefly  spent  on 
the  acetabulum.  J.  D,  G. 

t  I  allude  particularly  to  Desaalt.  —  A.  C. 
17 


130 


FRACTURES  OF  THE  UPPER  PART 


are  the  builders  of  the  body,  deposit  more  than  the 
absorbents  remove,  and  hence  is  derived  the  great 
source  of  its  growth.  In  the  middle  period  of  life 
the  arteries  and  absorbents  preserve  an  equilibrium 
of  action,  so  that,  with  a  due  portion  of  exercise, 
the  body  remains  stationary  ;  whilst  in  old  age  the 
balance  is  destroyed,  because  the  arteries  act  less 
than  the  absorbents,  and  hence  the  person  becomes 
diminished  in  weight ;  but  more  from  a  diminution 
of  the  arterial  than  from  an  increase  of  the  absorb- 
ent action.  This  is  well  seen  in  the  natural  changes 
of  the  bones,  their  increase  in  youth,  their  bulk, 
weight,  and  little  comparative  change  during  the 
adult  period,  and  the  lightness  and  softness  they  ac- 
quire in  the  more  advanced  stages  of  life  ;  hence 
the  bones  of  old  persons  may  be  cut  with  a  pen- 
knife, which  is  incapable  of  making;  any  Impression 
on  those  of  adults.  Even  the  neck  of  the  thigh- 
bone in  aged  persons  is  sometimes  undergoing  an 
interstitial  absorption,  by  which  it  becomes  shorten- 
ed, altered  in  its  angle  with  the  shaft  of  the  bone, 
and  so  changed  In  its  form  as  to  give  an  idea,  upon 
a  superficial  view,  that  it  has  been  the  subject  of 
fracture,  thus  leading  persons  into  the  erroneous  sup- 
position, that  the  bone  has  been  partially  broken 
and  reunited  ;  but  it  requires  very  little  knowledge 
of  anatomy  to  distinguish  in  the  skeleton,  the  bone 
of  advanced  age  from  that  of  the  middle  period  of 
life. 

^ge  at  which  it  occurs,  —  The  age  at  which  frac- 
tures of  the  neck  of  the  thigh-bone  within  the  cap- 
sular ligament  generally  occur,  is  a  most  important 
consideration ;  and  as  it  is  one  on  which  the  prac- 
tice to  be  pursued  by  the  surgeon  very  much  de- 
pends, 1  shall  take  the  liberty  of  making  the  follow- 
ing statement. 

1  have  been  forty  years  at  St  Thomas's  and  Guy^s 
Hospitals ;  and,  for  thirty  years,  have  had  more  than 


OF  THE  THIGH-BONE. 


131 


my  share,  and  mucli  more  than  I  merited,  of  the 
practice  of  London.  We  have  eight  hundred  and 
fiftj  patients  in  the  two  hospitals ;  and  1  believe 
that  in  the  two  hospitals,  eight  cases  of  fractures 
of  the  upper  part  of  the  thigh-bone  occur  in  each 
year ;  but  in  order  to  avoid  exceeding  the  average 
number,  1  will  consider  them  only  as  five  per  an- 
num; thirty-nine  multiplied  by  five,  produce  one 
hundred  and  ninety-five  ;  add  to  these  one  case  only 
in  each  year,  in  my  private  practice  of  thirty  years, 
they  will  collectively  amount  to  two  hundred  and 
twenty-five  cases ;  now,  in  that  time,  I  have  only 
known  two  cases  of  fracture  of  the  neck  of  the  thigh- 
bone within  the  capsular  ligament  occur  under  fift]j 
years  of  age;  one  was  in  a  patient  aged  thirty-eight, 
who  had  an  aneurism  of  the  iliac  artery  ;  and  the 
other  has  been  kindly  shown  to  me  by  that  excel- 
lent anatomist,  Mr  Herbert  Mayo. 

This  fracture,  then,  rarely  occurs  under  fifty  years 
of  age;  and  dislocation  seldom  at  a  more  advanced 
period,  although  there  are  exceptions  to  this  rule; 
for  I  have  myself  once  seen  the  fracture  at  thirty- 
eight  years  of  age,  but  it  was  very  oblique  ;  and  a 
dislocation  of  the  thigh  at  sixty-two;  but  the  period 
of  life  between  fifty  and  eighty  years  is  that  at 
which  the  fracture  most  usually  occurs;  for  from 
the  different  state  of  the  bone,  the  same  violence 
which  would  produce  dislocation  in  the  adult,  occa- 
sions fracture  in  old  age.  But  when  dislocation  does 
occur  between  the  age  of  sixty  and  seventy,  it  is  in 
persons  whose  constitutions  are  particularly  strong, 
and  in  whom  age  has  not  produced  those  changes  in 
the  bones  which  I  have  already  endeavoured  to 
point  out. 

Slight  cause  producing  this  fracture, —  That  this 
state  of  bone  in  old  age  tends  much  to  the  produc- 
tion of  fractures,  is  shown  by  the  slight  causes  which 
often  occasion  them.    In  London,  the  accident  most 


132 


FRACTURES   OF  THE  UPPER  PART 


frequently  occurs  when  persons,  walking  on  the  edge 
of  the  elevated  foot-path,  slip  upon  the  carriage 
pavement ;  though  the  descent  be  only  a  few  inches, 
yet,  being  sudden  and  unexpected,  and  the  force  act- 
ing perpendicularly,  with  the  advantage  of  a  lever 
in  the  cervix,  it  produces  a  fracture  of  the  neck  of 
the  thigh-bone;  and  as  a  fall  is  the  consequence,  the 
fracture  is  imputed,  by  ignorant  persons,  to  the  fall, 
and  not  to  its  true  cause.  Other  trival  accidents 
may  occasion  the  misfortune.  I  was  informed  by  a 
person  who  had  sustained  a  fracture  of  this  kind, 
that  being  at  her  counter,  and  suddenly  turning  to  a 
drawer  behind  her,  some  projection  in  the  floor 
caught  her  foot,  and  preventing  its  turning  w^ith  the 
body,  the  neck  of  the  thigh-bone  became  fractured. 
A  fall  upon  the  trochanter  major  will  also  produce 
it;  but  I  have  dwelt  particularly  on  the  slight  causes 
by  which  it  is  occasioned,  that  the  young  surgeon 
may  be  upon  his  guard  respecting  it,  as  he  might 
otherwise  believe  that  an  injury  of  such  importance 
could  scarcely  be  the  result  of  a  slight  accident,  and 
that  excessive  violence  is  necessary  to  break  the 
neck  of  the  thigh-bone  ;  such  an  opinion  is  as  liable 
to  be  injurious  to  his  reputation,  as  th6  error  of  con-^ 
founding  this  accident  with  dislocation. 

Union  of  this  fracture. — Much  difference  of 
opinion  has  existed  upon  the  subject  of  the  union  of 
the  fractured  neck  of  the  thigh-bone :  it  has  been 
asserted  that  these  fractures  unite  like  those  of  other 
parts  of  the  body;  but  the  dissections  which  I  made 
in  early  life,  and  the  opportunities  I  have  since  had 
of  confirming  my  observations,  have  convinced  me, 
that  fractures  of  the  neck  of  the  thigh-bone,— 
those  of  the  patella, —  olecranon,  —  and  condyles  of 
the  OS  humeri, —  and  that  of  the  coronoid  process 
of  the  u\n'a,  genera  I  hj  unite  by  ligament,  and  not  by 
bone.  This  principle  I  have  taught  in  my  lectures 
for  thirty  years;  i^nd  it  is  a  most  essential  point,  as 


OF  THE  THIGH-BONE. 


133 


it  affects  the  reputation  of  the  surgeon.  I  was  called 
to  a  case  of  this  fracture,  in  which  the  medical  at- 
tendant had  been  promising,  week  after  week,  an 
union  of  the  fracture,  and  the  restoration  of  a  sound 
and  useful  limb.  After  many  weeks,  the  patient 
became  anxious  for  further  advice:  I  did  all  in  my 
power  to  lessen  the  erroneous  impression  which  had 
been  madei,  bj  telling  the  patient  that  she  might  ul- 
timately walk,  although  with  some  lameness:  and 
taking  the  surgeon  into  another  room,  asked  him 
upon  what  grounds  he  was  led  to  suppose  there  would 
be  union,  to  which  he  replied,  he  was  not  aware  but 
that  the  fracture  of  the  neck  of  the  thigh-bone  would 
unite  like  those  of  other  bones  of  the  body.  The 
case,  however,  proved  unfortunate  for  his  character, 
as  this  patient  did  not  recover  in  tiie  usual  degree. 

Young  medical  men  find  it  so  much  easier  a  task 
to  speculate  than  to  observe,  that  they  are  too  apt 
to  be  pleased  with  some  sweeping  theory,  which 
saves  them  the  trouble  of  observing  the  processes 
of  nature  ;  and  they  have  afterwards,  when  they 
embark  in  their  professional  practice,  not  only  every 
thing  still  to  learn,  but  also  to  abandon  those  false 
impressions  which  hypothesis  is  sure  to  create. 
Nothing  is  known  in  our  profession  by  guess  ;  and  I 
do  not  believe,  that  from  the  first  dawn. of  medical 
science  to  the  present  moment,  a  single  correct  idea 
has  ever  emanated  from  conjecture  :  it  is  right, 
therefore,  that  those  who  are  studying  their  profes- 
sion, should  be  aware  that  there  is  no  short  road  to 
knowledge  ;  that  observations  on  the  diseased  living, 
examinations  of  the  dead,  and  experiments  upon 
living  animals,  are  the  only  sources  of  true  knowl- 
edge ;  and  that  inductions  from  these  are  the  sole 
basis  of  legitimate  theory. 

In  all  the  examinations  which  I  have  made  of 
transverse  fractures  of  the  cervix  femoris  entirely 


134  FRACTURES    OF  THE  UPPER  PART 


within  the  capsular  hgament,  1  have  never  met  with 
one  in  which  a  bony  union  had  taken  place,  or  which 
did  not  admit  of  a  motion  of  one  bone  upon  the 
other.  To  deny  the  possibility  of  this  union,  and  to 
maintain  that  no  exception  to  the  general  rule  can 
take  place,  would  be  presumptuous,  especially  when 
we  consider  the  varieties  of  direction  in  which  a 
fracture  may  occur,  and  the  degree  of  violence  by 
which  it  may  have  been  produced;  as,  for  example, 
when  the  fracture  is  through  the  head  of  the  bone,* 
and  there  is  no  separation  of  the  fractured  ends;  or, 
when  the  bone  is  broken  without  its  periosteum 
being  torn;  or,  when  it  is  broken  obliquely,  partly 
within  and  partly  externally  to  the  capsular  liga- 
ment; but  I  wish  to  be  understood  to  say,  that  if 
ever  it  does  happen,  it  is  of  extremely  rare  occur- 
rence, and  that  I  have  not  yet  met  with  a  single 
decisive  example  of  it.t  As  a  proof  that  the  gene- 
ral principle  which  I  have  stated  is  correct,  I  sub- 
join the  following  account  of  forty-three  cases,  from 
different  collections,  of  non-union  by  bone,  in  frac- 
tures of  the  neck  of  the  thjgh-bone, 

*  Much  trouble  has  been  taken  to  impress  the  minds  of  the 
public  with  the  idea,  that  1  have  in  this  work  denied  the  possi- 
bility of  union  of  the  fracture  of  the  neck  of  the  thigh-bone ; 
and  therefore  I  beg-  at  once  to  be  understood,  that  I  believe  the 
reason  why  fractures  of  the  neck  of  the  thigh-bone  do  not  Unite 
is,  that  the  ligamentous  sheath  and  periosteum  of  the  neck  of 
the  bone  is  torn  through,  and  that  there  is,  in  consequence  of 
this  circumstance,  a  want  of  nourishment  of  the  head  of  the 
bone  ;  but  if  a  fracture  should  happen  without  the  reflected 
ligament  being  torn^  I  can  readily  believe  that  as  the  nutrition 
would  continue,  the  bone  might  unite  ;  but  the  character  of  the 
accident  would  differ;  the  nature  of  the  injury  could  scarcely 
be  discerned,  and  the  patient's  bone  would  unite  with  little  at- 
tention on  the  part  of  the  surgeon.  —  A.  C. 

t  In  Mr  Cross's  account  of  his  visit  to  the  French  hospitals, 
some  interesting  matter  upon  this  subject  will  be  found.  —  A.  C. 


OF  THE  THIGH-BONE. 


135 


7  specimens, 

1  ditto. 
6  ditto. 

12  ditto. 

6  ditto. 

6  ditto. 

2  ditto. 
2  ditto. 
1  ditto. 

43 

To  these  I  have  to  add  another,  from  an  experi- 
ment upon  a  living  animal  ;  while,  on  the  contrary, 
only  a  single  instance  meriting  a  moment's  attention 
has  yet  been  produced  :  in  this  case,  the  same  ap- 
pearances were  found  in  both  the  thigh-bones  ;  and 
even  these  resembled  Avhat  1  have  several  times 
observed  in  the  dead  body,  arising  from  a  softened 
state  of  the  bones.  I  have  given  a  plate  of  some 
of  these  appearances,  and  the  preparations  I  shall 
at  all  times  be  happy  to  show  to  any  of  my  profes- 
sional brethren  who  may  wish  to  see  them.* 

*  The  observations  of  one  whose  experience  and  opportuni- 
ties have  been  so  singularly  good  as  those  of  Sir  A.  Cooper,  in 
addition  to  what  has  been  advanced  on  the  same  subject  by 
other  celebrated  surgeons,  must  convince  the  reader  of  the 
impropriety  of  crediting  such  loose  and  general  assertions  as 
are  to  be  found  in  many  of  the  popular  works  on  surgery,  es- 
pecially in  relation  to  the  practicability  of  procuring  a  bony 
union,  when  the  neck  of  the  thigh-bone  has  been  fractured 
within  the  capsule.  Desault  in  particular  writes  with  his  usual 
extravagance  on  this  topic,  and  concludes  by  saying  '  that  the 
progress  of  these  fractures  is  the  mine  with  that  of  all  others, 
and  that  when  treated  with  equal  skilly  there  is  no  reason  why 
their  termination  should  not  be  equally  favourable.''  Though 
we  can  believe  in  the  possibility  of  a  cure  by  bony  union  in 
such  a  case,  yet  as  the  uniform  experience  of  a  majority  of  the 
most  enlightened  surgeons,  is  against  such  a  recovery,  we  should 
recommend,  that  the  young  practitioner  be  careful  not  to  injure 


In  the  collection  at  St  Thomas's, 
In  the  college  of  surgeons, 
In  St  Bartholomew's, 
At  Dublin, 

In  Mr  Langstaff's,  of  Basinghall-street, 

In  Mr  Bell's  and  Mr  Shaw's, 

In  Mr  Brookes's, 

In  DrMunro's, 

Mr  Mayo's  collection, 


136  FRACTURES  OF  THE  UPPER  PART 

Cause  of  the  want  of  union.  —  Having  thus  ex- 
plained the  ordinary  result  of  these  cases  in  rela- 
tion to  their  want  of  union,  I  shall  now  proceed  to 
state  the  reasons  which  may  be  assigned  for  the 
absence  of  ossific  union  in  the  transverse  fracture 
of  the  neck  of  the  thigh-bone  within  the  capsular 
ligament. 

Want  of  proper  apposition,  —  The  first  reason  is 
the  want  of  proper  apposition  of  the  bones:  for  if 
their  broken  extremities  in  any  part  of  the  body 
be  kept  much  asunder,  ossific  union  is  prevented. 

In  a  boy,  who  had  a  compound  fracture  of  the 
tibia,  without  the  fibula  beino^  broken,*  and  who  had 
the  protruded  end  sawn  off,  the  two  extremities 
were  prevented  from  coming  in  contact  by  the  fibu- 
la, and  union  never  occurred.  My  friend,  Mr  Smith, 
an  excellent  surgeon,  at  Bristol,  had  a  similar  case 
under  his  care,  in  which  a  portion  of  the  tibia  hav- 
ing been  sawn  otF,  the  fibula,  remaining  whole,  pre- 
vented ossific  union. t 


his  own  reputation  and  profession  by  rashly  prognosticating 
what  can  rarely  or  ever  be  realized.  In  Dorsey's  Elements 
(vol.  i,  p.  193,)  the  ideas  of  Desaiilt  are  repeated.  All  the 
cases  referred  to  by  Boyer  and  Desault,  may  be  explained  by 
recurring  to  what  our  author  has  said  on  the  changes  produced 
in  the  bones  by  age.  J.  D.  G. 

*  If  the  fibula  be  broken,  large  pieces  of  the  tibia  will  sepa- 
rate, and  yet  ossific  union  will  ensue.  —  A.  C. 

t  The  particulars  of  the  case  were  as  follow:  —  The  boy 
was  admitted  into  the  Bristol  Infirmary  for  disease  of  the  tibia  ; 
and  the  diseased  portion  not  exceeding  more  than  from  two  to 
three  inches  in  length,  that  part  of  the  bone  was  removed  by 
the  saw.  In  a  month  the  limb  had  acquired  so  much  firmness, 
that  the  boy  was  permitted  to  walk  about  the  ward,  which  he 
was  able  to  perform  tolerably  well,  and  in  six  weeks  no  doubt 
was  entertained  that  ossification  had  taken  place  in  the  uniting 
substance  ;  at  this  time  he  sickened  with  the  small  pox  and 
died.  Upon  examination,  the  edges  of  the  extremities  of  the 
tibia  were  found  absorbed  and  rounded,  and  on  the  inferior  por- 


OF  THE  THIGH-BONE. 


137 


This  fact  is  easily  seen  by  experiments  on  ani^ 
mals :  1  sawed  seven-eighths  of  an  inch  of  the  ra- 
dius from  a  rabbit,  and  the  ends  of  the  bones  were 
not  united  to  each  other,  but  only  to  the  ulna.  I 
also  sawed  off  the  extremity  of  the  os  calcis,*and 
suffered  it  to  be  drawn  up  by  the  action  of  the  gas- 
trocnemius muscle,  and  it  united  only  by  ligament. 
(See  Plates.) 

The  following  communication  is  from  Mr  Benja* 
min  Bell,  of  Edinburgh.^' 

26,  aS^^  Andrew  Square,  Edinburgh  ; 

August  1th,  1823. 

My  dear  Sir:  — Excuse  the  freedom  I  take  in 
communicating  to  you  the  outline  of  a  case,  the  re- 
sult of  which  I  had  an  opportunity  of  observing  a 
short  time  ago;  as  it  is  connected  with  the  subject 
so  admirably  developed  in  your  late  valuable  publi- 
cation, it  may,  perhaps,  prove  interesting.  In  the 
progress  of  a  tour  through  some  parts  of  Cumber- 
land last  month,  I  had  occasion  to  visit  Whitehaven; 
Mr  Fox,  an  able  and  intelligent  surgeon,  of  that 
place,  was  so  kind  as  to  show  me  the  case  alluded 

tion  a  bony  callus  had  formed,  about  three  quarters  of  an  inch 
in  extent;  no  ossific  matter  was  discoverable  in  the  greater 
part  of  the  space  originally  occupied  by  the  diseased  bone,  but 
a  tough,  though  thin  ligamentous  band  extended  from  the  supe- 
rior to  the  inferior  portion  of  the  tibia. —  See  Medical  Records 
and  Researches.  —  A.  C. 

*  A  highly  respectable  and  intelligent  individual ;  grandson 
of  Mr  Benjamin  Bell,  who  was  a  most  useful  man  to  the  pro- 
fession by  his  publications  :  and  son  of  Mr  George  Bell,  also  a 
most  able  surgeon,  of  Edinburgh  :  Mr  Bell  is  likely  to  be  a 
worthy  successor  to  such  a  father. —  A.  C. 

IB 


138 


FRACTURES  OF  THE  UPPER  PART 


to.  He  was  also  so  good  as  to  favour  me  with  an 
account  of  its  progress. 

Case,— June,  1822. —  William  Coulthard,  aged 
thirtj-five,  of  a  plethoric  hahit,  a  miner,  while  stem- 
ming a  bore,  preparatory  to  blasting  a  rock,  the 
powder,  in  consequence  of  the  friction,  inflamed, 
and  exploding,  gave  rise  to  the  following  accident  : 
—  One  portion  of  the  rock  struck  him  in  the  peri- 
nasum,  and  occasioned  a  compound  fracture  of  the 
tuberosity  of  the  left  ischium,  which  was  followed 
by  profuse  haemorrhage.  Another  portion  of  the 
rock  came  in  contact  with  the  left  leg,  about  four 
inches  below  the  knee,  and  shatteied  the  tibia  and 
fibula.  Four  large  loose  pieces  of  bone  were  ex- 
tracted, by  Mr  Fox,  immediately  after  the  accident. 
These  portions,  when  united,  formed  about  six 
inches  of  the  entire  cylinder  of  the  tibia.  The 
sides  of  the  wound  were  then  drawn  together,  and 
retained  '  in  situ'  by  adhesive  plasters.-  The  limb 
was  placed  in  a  proper  position,  and  secured  by  pads 
and  wooden  splints.  In  a  short  time  the  wound  in 
the  leg  healed  up;  three  months,  however,  after  it 
had  healed,  an  abscess  formed,  and  another  small 
portion  of  bone  came  away,  probably  a  part  of  the 
fibula.  The  wound  healed  again  without  any  unto- 
ward symptom. 

The  day  on  which  I  saw  him  (July  22nd,  1823), 
the  leg  in  which  the  injury  had  occurred  appeared 
to  be  about  two  inches  shorter  than  the  other.  A 
large  cicatrix  occupied  the  fore  and  middle  part  of 
the  shin;  the  patient  could  extend  the  leg  and 
stamp  on  the  floor  with  considerable  force;  the 
muscles  were  plump  and  ffrm  ;  but  the  leg  was  to  a 
certain  extent  flexible,  and  could  be  slightly  bent  by 
the  hands  in  four  different  directions  :  backwards, 


OF  THE  THIGH-BONE. 


139 


forwards,  to  the  right  and  to  the  left,  on  seizing  it 
below  the  knee  (above  the  fracture),  and  at  the 
ankle.  He  suffered  no  pain,  and  permitted  the 
limb  to  be  freely  handled,  but  could  not,  at  that 
time,  bear  the  whole  weight  of  the  body  upon  it. 
It  seemed  to  me  as  if  the  space  between  the  two 
ends  of  the  fractured  bones  had  been  filled  up  with 
a  sort  of  ligamento-cartilaginous  matter,  resembling 
that  found  in  cases  of  fracture  of  the  neck  of  the 
femur  external  to  the  ligament,  or  in  that  occur- 
ring in  ill-treated  cases  of  transverse  fracture  of 
the  patella.  Whether  that  conjecture  be  right  or 
not,  it  is  difficult  to  determine. 

A  number  of  small  pieces  of  bone  hav^  been  ex- 
tracted from  the  wound  in  the  perinoeum,  and  a 
pretty  large  loose  portion  can  be  felt  at  present  with 
the  probe.  In  other  respects  the  man's  health  is 
good,  and  he  expresses  an  anxious  desire  to  return 
to  his  work. 

Your  much  obliged, 

And  sincerely  grateful  Pupil, 

Benjamin  Bell, 

The  neck  of  the  thigh-bone  when  broken,  is 
placed  under  similar  circumstances  ;  for,  by  the  con- 
traction of  the  rnuscles,  it  is  no  longer  in  apposition 
with  the  head  of  the  bone,  and  is,  therefore,  pre- 
vented from  uniting;  if  this,  however,  were  the 
only  obstacle,  it  would  be  argued  that  the  retraction 
of  the  thigh-bone  might  be  prevented  by  bandaging 
and  extension,  the  truth  of  which  cannot  be  denied; 
but  it  is  scarcely  possible,  even  for  a  few  hours,  to 
preserve  the  limb  in  exact  apposition,  as  the  patient, 
on  the  slightest  change  of  posture,  produces  instant 
retraction,  by  bringing  into  action  those  powerful 


140  FRACTURES  OF  THE  UPPER  PART 


muscles  which  pass  from  the  pelvis  to  the  thigh- 
bone. 

So  in  fractures  of  the  patella,  although  we  often 
do  all  in  our  power  to  prevent  retraction  of  the 
muscles,  yet  it  very  rarely  happens  that  we  are  able 
to  support  a  con)plete  approximation  of  the  bonee. 

Msence  of  coritinned  pressure,  —  The  second  cir- 
cumstance which  prevents  a  bony  union  in  these' 
fractures  is,  the  want  of  pressure  of  one  bone  upon 
the  other,  even  if  the  length  of  the  limb  were  pre- 
served :  and  this  will  operate  in  preventing  an  os- 
sific  union  in  cases  where  the  capsular  ligament  is 
not  torn  ;  and  in  all  those  which  I  have  had  an  op- 
portunity ©f  examining,  it  has  not  been  lacerated. 
The  circumstance  to  which  I  allude  proceeds  from 
the  secretion  of  a  quantity  of  fluid  into  the  joint ; 
from  the  increased  determination  of  blood  to  the 
capsular  ligament  and  synovial  membrane  ;  a  super- 
abundance of  serous  synovia,  —  that  is,  synovia  much 
less  mucilaginous  than  usual, —  which  extends  the 
ligament,  and  thus  entirely  prevents  the  contact  of 
the  bones,  by  pushing  the  upper  end  of  the  body  of 
the  thigh-bone  from  the  acetabulum.  After  a  time 
this  fluid  becomes  absorbed,  but  not  until  the  inflam- 
matory process  has  ceased,  and  ligamentous  matter 
has  been  efl'used  into  the  joint  from  the  interior  of 
the  synovial  surface.  The  muscles,  also,  do  not  in 
this  accident  produce  pressure  between  the  broken 
extremities  of  bones,  which  so  greatly  conduces  to 
the  union  of  other  fractures;  for  if  two  broken 
bones  overlap  each  other,  on  that  side  on  which  they 
are  pressed  together,  there  is  an  abundant  ossific 
deposit:  but  on  the  opposite  side,  where  there  is  no 
pressure,  scarcely  any  change  is  observed.  So  also 
we  find  that,  if  the  ends  of  the  bones  be  drawn  from 
each  other  by  the  action  of  muscles,  as  sometimes 
happens  in  the  fractures  of  the  os  femoris,  tibia,  os 


OF   THE  THIGH-BONE. 


141 


humeri,  radius  and  ulna,  union  is  not  effected  until 
the  surgeon,  by  a  strong  leathern  bandage  tightly 
buckled  around  the  limb,  compels  the  bones  to  press 
upon  each  other,  and  thus  support  tfie  necessary  in- 
flammation for  the  production  of  ossific  union.  When 
a  fracture  occurs  amidst  muscles,  those  which  are 
inserted  into  the  fractured  part  of  the  bone,  have 
generally  a  tendency  to  keep  the  extremities  of  the 
bones  together,  with  some  few  exceptions;  but  when 
a  fracture  occurs  in  the  neck  of  the  thigh-bone,  the 
muscles  have  only  an  influence  upon  one  portion  of 
the  fractured  bone;  and  this  influence  serves  to  draw 
one  part  from  the  other. 

Liittle  action  in  the  head  of  the  bone,  —  But  the 
third  and  principal  reason  which  may  be  assigned 
for  the  want  of  union  of  this  fracture  is,  the  almost 
entire  absence  of  ossific  action  in  the  head  of  the 
thigh-bone  when  separated  from  its  cervix;  its  life 
being  supported  by  the  llgamentum  teres,  which  has 
only  a  few  minute  vessels,  ramifying  from  it  to  the 
head  of  the  bone.*  The  structure  of  the  neck  of 
the  thigh-bone,  and  of  the  parts  surrounding  it,  is  ex- 
plained in  the  account  of  the  anatomical  plate  con- 
nected with  this  part  of  my  subject.  But  here  it 
may  be  observed,  that  the  neck  and  head  of  the 
thigh-bone  are  naturally  supplied  with  blood  by  the 
periosteum  of  the  cervix,  and  that  when  the  bone 
is  fractured,  if,  as  most  frequently  happens,  the  pe- 

*  In  reviewing  what  I  have  written  on  the  structure  of  the 
head  and  neck  of  the  thigh-hone,  1  fear  that  some  misconcep- 
tion might  arise,  of  this  passage,  in  which  I  say  that  the  head 
and  neck  of  the  bone  are  supplied  with  vessels  from  the  reflect- 
ed ligament  and  hgamentum  teres.  Now  1  do  not  mean  that 
this  is  the  only  supply,,  for  it  is  well  known  that  vessels  pass 
through  the  interior  of  the  neck  of  the  bone  ;  bul  as  these  are 
torn  through  by  the  fracture,  only  those  of  the  untorn  reflected 
ligament  and  ligamentum  teres  remain,  and  it  is  principally  those 
jof  which  I  have  given  a  view  in  plate  13.  —  A.  C. 


142  FRACTURES  OP  THE  UPPER  PART 


riosteurn  be  torn  through,  the  means  of  ossific  ac- 
tion are,  in  consequence  of  such  fracture  and  lacer- 
ation, necessarily  destroyed  in  the  head  of  the  bone. 
Scarcely  any  change,  therefore,  takes  place  in  the 
head  or  neck  of  the  bone  attached  to  it ;  no  deposit 
of  cartilage  or  bone,  similar  to  that  of  the  other 
fractured  bones,  is  produced  ;  but  the  deposit  which 
does  take  place,  as  will  be  seen  in  the  plates  of  frac- 
ture of  the  neck  of  the  thigh-bone,  consists  of  liga- 
mentous matter,  covering  the  surface  of  the  cancel- 
lated structure  with  little  patches  like  ivory  on  the 
head  of  the  bone.* 

Dissection  of  this  fracture,  —  The  appearances 
which  are  found  on  the  dissection  of  these  injuries 
are  as  follow  :  —  the  head  of  the  bone  remains  in 
the  acetabulum  attached  by  the  ligamentum  teres. 
There  are,  upon  parts  of  the  head  of  the  bone, 
very  small  white  spots  like  ivory.  The  cervix  is 
sometimes  broken  directly  transversely,  at  others 
with  obliquity.  The  cancellated  structure  of  the 
broken  surface  of  the  head  of  the  bone  and  of  the 
cervix,  is  hollowed  by  the.  occasional  pressure  of  the 
neck  attached  to  the  trochanter,  and  consequent  ab^ 
sorption;  and  this  surface  is  sometimes  partially 
coated  with  a  ligamento-cartilaginous  deposit.  The 
cancelli  are  rendered  firm  and  smooth  by  friction,  as 
we  see  in  other  bones  which  rub  upon  each  other  . 
when  their  articular  cartilages  are  absorbed.  Por- 
tions of  bone  are  formed  or  broken  off,  and  these 
are  found  either  attached  by  means  of  ligament,  or 
floating  loosely  in  the  joint,  covered  by  a  ligament- 
ous matter;  but  these  pieces  do  not  act  as  extrane- 

*  But  if  I  attempt  to  prevent  union  in  a  fracture  external  to 
a  joint,  1  find,  by  moving  the  bone  from  time  to  time,  that  in 
proportion  to  that  motion  is  the  quantity  of  callus  produced  ; 
which  is  just  the  reverse  in  the  accidents  I  am  now  describing, 
—  A.  C. 


OP  THE  THIGH-BONE. 


143 


0U9  bodies,  so  as  to  excite  inflammation,  and  thus 
produce  their  discharge,  any  more  than  those  loose 
portions  of  bone  covered  by  cartilage,  which  are 
found  so  frequently  in  the  knee,  and  sometimes  in 
the  hip  and  elbow-joints.  With  respect  to  the  neck 
of  the  bone  which  remains  attached  to  the  trochan- 
ter major,  the  most  remarkable  circumstance  is,  that 
it  soon  becomes  in  a  great  degree  absorbed,  only  a 
small  portion  of  it  remaining ;  its  surface  is  yellow, 
and  extremely  smooth,  if  the  bones  have  rubbed 
against  each  other.  Some  ossific  deposition  I  have 
seen  manifested  around  this  small  remaining  part  of 
the  neck  of  the  bone,  and  upon  the  trochanter  ma- 
jor and  thigh-bone  below  it,  in  several  examples  of 
this  fracture.  We  do  not,  however,  observe  the 
same  process  of  union  as  in  other  bones,  but  a  liga- 
mentous instead  of  an  ossific  union. 

Ligainent  and  synovial  membrane.  —  The  capsular 
ligament  enclosing  the  head  and  neck  of  the  bone 
becomes  much  thicker  than  natural,  but  the  synovial 
membrane  undergoes  the  greatest  change  from  in- 
flammation, being  very  much  thickened,  not  only 
upon  the  capsular  ligament,  but  also  upon  the  re- 
flected portion  of  that  ligament  upon  the  nqpk  of 
the  bone,  as  far  as  the  edge  of  the  fracture. 

Effusion  into  the  joint ;  new  ligament^  8^c.  —  With* 
in  the  articulation  is  found  a  large  quantity  of  serous 
synovia  ;  by  which  term  I  mean  to  express,  that  the 
synovia  is  less  mucilaginous,  and  contains  more  serum 
than  usual,  mixed  with  a  small  quantity  of  blood; 
this  fluid,  by  gradually  extending  the  ligament,  sepa- 
rates for  a  time  one  portion  of  bone  from  the  other; 
it  is  produced  by  the  inflammatory  process,  and  be- 
comes absorbed  when  the  irritation  in  the  part  sub- 
sides. I  do  not  know  the  exact  period  at  which 
this  change  takes  place,  but  I  have  seen  it  in  the 
recent  state  of  the  injury.    Into  this  fluid  is  poured 


144 


FRACTURES  OF  THE   UPPER  PART 


a  quantity  of  ligamentous  matter,  by  the  adhesive 
inflammation  excited  in  the  synovial  membrane,  and 
flakes  of  it  are  found  proceeding  from  its  internal 
surface,  uniting  it  to  the  edge  of  the  head  of  the 
bone.  Thus  the  cavity  of  the  joint  becomes  dis- 
tended, in  part  by  an  increased  secretion  of  synovia, 
and  in  part  by  the  solid  effusion  which  the  adhesive 
inflammation  produces  :  the  membrane  reflected  on 
the  cervix  femoris  is  sometimes  separated  from  the 
fractured  portions,  so  as  to  form  a  band  from  the 
fractured  edge  of  the  cervix  to  that  of  the  head  of 
the  bone  ;  bands  also  of  ligamentous  matter  pass 
from  the  cancellated  structure  of  the  cervix  to  the 
head  of  the  bone,  serving  to  unite,  by  this  flexible 
material,  the  one  broken  portion  of  bone  with  the 
other. 

The  trochanter  is  drawn  up,  more  or  less,  in  diffe- 
rent accidents  ;  and  in  those  cases  in  which  it  is  very 
much  elevated,  I  have  known  a  considerable  ossific 
deposit  take  place  upon  the  body  of  the  thigh-bone, 
between  the  trochanter  major  and  the  trochanter 
minor.  When  the  bone  has  been  macerated,  its 
head  is  much  lighter  and  more  spongy  than  in  the 
healtUy  state,  excepting  on  those  parts  most  exposed 
to  friction,  where  it  is  rendered  smooth  by  the  attri- 
tion which  gives  it  a  polished  surface. 

These,  then,  are  the  usual  appearances  on  dissec- 
tion :  there  are,  however,  two  preparations  in  the 
Royal  College  of  Surgeons  in  London,  which  have 
been  sent  as  specimens  of  union  by  bone  of  the  cer- 
vix femoris ;  but  as  I  may  be  thought  prejudiced  in 
favour  of  the  opinion  I  have  advanced,  I  shall  give 
that  of  an  excellent  anatomist,  whose  loss  we  have 
had  lately  to  deplore.  Mr  Wilson  says,  '  1  have  ex- 
amined very  attentively  these  two  preparations,  and 
cannot  perceive  one  decisive  proof  in  either,  of  the  bones 
having  been  actually  fractured,'* 


OF  THE  THIGH-BONE. 


145 


This  circumstance,  of  want  of  ossific  union,  is  not 
peculiar  to  the  neck  of  the  femur,  as  will  be  seen  in 
our  account  of  fractures  of  the  condyles  of  the  os 
humeri,  of  the  coronoid  process  of  the  ulna,  and  of 
bones  generally,  when  seated  within  the  capsular 
ligament. 

It  appears  then,  as  a  general  principle,  from  the 
account  which  I  have  given  of  the  dissection  of  those 
whose  bodies  have  been  examined  after  having  suffer- 
ed from  this  fracture,  that  ossific  union  is  not  pro- 
duced; that  nature  makes  slight  attempts  for. its 
production  upon  the  neck  of  the  bone,  and  upon  the 
trochanter  major,  but  scarcely  any  upon  the  head  of 
the  bone;  and  that  if  union  be  produced,  it  is  by 
means  of  ligament. 

Mr  Stanley,  for  whom,  both  as  an  anatomist  and 
a  surgeon,  I  have  great  respect,  has  met  with  the 
appearance  of  fracture  in  the  neck  of  each  thigh- 
bone, in  the  same  subject.  1  do  not  mean  to  deny 
the  possibility  of  the  necks  of  both  thigh-bones  in 
this  subject  having  been  fractured,  because  that  point 
can  only  be  determined  by  the  history  of  the  acci- 
dent, and  by  a  very  careful  and  accurate  examination 
of  several  sections  of  the  bones;  but  I  can  show  that 
similar  effects  are  produced  by  disease. 

The  neck  of  the  thigh-bone  in  adult  persons  of 
middle  age,  has  a  close  cancellated  structure,  with 
considerable  thickness  of  the  shell  which  covers  it ; 
but  in  old  subjects,  the  cancellated  structure  of  the 
shaft  of  the  bone,  which  is  formed  of  a  coarse  net- 
work, loaded  with  adipose  matter,  is  often  extended 
into  the  neck  of  the  bone,  and  the  shell  which  cov- 
ers it  becomes  so  thin,  that  when  a  section  is  made 
through  the  middle  of  the  head  and  cervix,  it  is 
found  diaphanous;  of  this  I  have  several  specimens. 
As  the  shell  becomes  thin,  ossific  matter  is  deposited 
on  the  upper  side  of  the  cervix,  opposite  the  edge 
19 


146 


FRACTURES  OF  THE  UPPER  PART 


of  the  acetabulum,  and  often  a  similar  portion  at  its 
lower  part,  and  thus  the  strength  of  the  bone  is  in 
some  degree  preserved ;  this  state  may  be  frequently 
seen  in  very  old  persons.  Mr  Steel,  of  Berkhamp- 
stead,  one  of  the  most  intelligent  surgeons,  and  most 
respectable  men  1  know,  gave  me  the  thigh-bone  of 
a  person  thus  altered,  whose  age  was  ninety-three. 

When  the  absorption  of  the  neck  proceeds  faster 
than  the  deposit  on  its  surface,  the  bone  breaks  from 
the  slightest  causes,  and  this  deposit  wears  so  much 
the  appearance  of  an  united  fracture,  that  it  might 
be  easily  mistaken  for  it.  Before  the  bone  thus 
alters,  we  sometimes  meet  with  a  remarkable  but- 
tress shooting  up  from  the  shaft  of  the  bone  into  its 
head,  giving  it  additional  support  to  that  which  it 
receives  from  the  deposit  of  bone  upon  its  external 
surface.  But  another  change  is  also  produced  from 
disease,  of  which  the  following  is  the  history,  and 
which  directly  applies  to  the  subject  before  us. 

Old  bed-ridden  and  fat  persons  (generally  females), 
are  often  brought  into  our  dissecting-room  with  some 
of  their  bones  broken  (and  more  frequently  the  thigh- 
bone than  any  other)  in  being  removed  from  the 
grave.  If  the  cervix  femoris  of  such  persons  be 
examined,  it  will  be  found  that  the  head  of  the  bone 
is  sunken  down  upon  its  shaft,  and  that  the  neck  of 
the  thigh-bone  is  shortened,  so  that  its  head  is  in 
contact  with  the  shaft  of  the  bone  opposite  to  the 
trochanter  minor;  and  at  the  part  at  which  the 
ligament  is  inserted  into  the  neck  of  the  bone,  the 
phosphate  of  lime  is  absorbed,  and  a  ligamento-car- 
tilaginous  substance  occupies  its  place  ;  either  ex- 
tending entirely  through  the  neck  of  the  bone,  or 
partially,  so  that  one  section  exhibits  signs  of  it, 
and  in  another  it  is  wanting.  The  bone,  in  some 
cases,  is  so  soft  and  fragile,  both  in  its  trochanter  and 
head,  that  it  will  scarcely  bear  the  slightest  hand- 


OF  THE  THIGH-BONE.  147 

ling;  and  the  motion  of  the  thigh-bones  in  the  aceta- 
bulum is  almost  entiielj  lost,  so  that  ihe  persons 
must  have  had  little  use  in  their  lower  extremities. 

During  the  last  winter  we  had  two  instances  of 
■  this  alteration  in  the  neck  of  the  bone,  and  it  is  an 
appearance  which  1  have  several  times  seen. 

In  examining  the  body  of  an  old  subject,  very 
much  loaded  with  fat,  in  the  dissecting-room  of  St 
Thomas's  Hospital,  1  found  lhat  the  gentleman  who 
had  dissected  one  limb,  had  cut  through  the  ca[)sular 
ligament  of  the  hip-joint,  and  tried  to  remove  the 
head  of  the  thigh-bone  from  the  acetabulum  ;  but 
the  neck  of  the  bone  broke  on  the  employment  of  a 
very  slight  force,  and  upon  a  further  trial  to  remove 
it,  the  bone  crumbled  under  his  fingers.  As  the 
other  limb  was  not  yet  dissected,  I  requested  Mr 
South,  one  of  our  demonstrators,  to  remove,  with 
care,  the  upper  part  of  the  thigh-bone;  but  although 
he  used  great  caution  in  doing  it,  he  could  not  re- 
move the  bone  without  fracturing  the  upper  part  of 
its  shaft ;  but  he  succeeded  in  removing  the  upper 
part  of  the  bone,  so  that  it  might  be  preserved;  and 
of  this  I  have  given  plates. 

We  have  here,  then,  a  case  in  which  the  neck  of 
the  bone  was  absorbed,  so  that  the  head  was  brought 
in  contact  with  the  trochanter;  in  which,  most  de- 
cidedly, there  had  not  l^ee'n  a  fracture,  although  it 
had  in  some  parts  the  appearatice  of  one;  and  in 
which  the  dis6ase  occurred  in  each  hip-joint. 

Another  case  of  the  same  kind  was  examined  by 
Mr  Soutb,.  daring  the  last  winter,  which,  so  far  as  it 
relates  to  the  Softened  state  of  the  upper  part  of  the 
thigh-bone,  Avas  similar  to  the  former;  the  heads 
were  spongy,  the  necks  were  shortened,  so  that 
there  was  scarcely  any  remaining ;  each  trochanter 
was  light  in  weight,  spongy,  and  very  large ;  and 
there  was  little  if  any  motion  in  either  of  the  hip- 


148  FRACTURES  OF  THE  UPPER  PART 

joints;  so  that  both  limbs  appeared,  at  first  sight,  as 
if  dislocated  upon  the  pubes. 

But  the  best  specimen  of  this  state  of  the  bone  is 
the  following,  which  I  preserve  with  the  most  assid- 
uous care,  and  value  in  the  highest  possible  degree:- 
—  I  have  had  for  twenty  years  in  the  collection  of 
St  Thomas's  Hospital,  the  thigh-hone  of  an  old 
person,  in  which  the  head  of  the  bone  had  sunken 
towards  its  shaft.  I  have  been  in  the  habit  of 
showing  this  bone  twice  a  year  as  a  specimen  how 
bones  sometimes  become  soft  from  age  and  disease, 
and  from  the  absorption  of  their  phosphate  of  lime; 
and  I  have  frequently  cut  with  a  penknife  both  its 
head  and  its  condyles,  to  show  this  softened  state. 
On  sawing  through  its  cervix,  the  cartilage,  deprived 
of  its  phosphate  of  lime,  had  dried  away  in  several 
parts,  and  the  appearance  was  such  that  a  person. 
Ignorant  of  the  change,  would  have  declared  it  to  be 
a  fracture  ;  only,  that  in  some  sections  the  cartilage 
had  taken  different  directions,  and  in  some  the  bone 
was  not  yet  entirely  absorbed.  There  is  also  in  the 
Museum  of  St  Thomas's  Hospital,  a  skeleton  in 
which  both  the  thigh-bones,  and  each  os  humeri,  are, 
in  a  subject  extremely  altered  by  rickets,  divided 
by  similar  portions  of  cartilage,  in  which  no  ossific 
matter  exists. 

The  plates  which  are  appended  will  afford  better 
ideas  of  those  morbid  changes  than  words  can  con- 
vey ;  and  I  hope  Mr  Stanley,  also,  will  give  plates 
of  his  preparations ;  hoth^  however,  should  be  en- 
graved, as,  without  both,  the  public  cannot  form  a 
correct  opinion. 

I  have  been  led  to  prosecute  the  inquiry  by  ex- 
periments upon  animals.  I  found  it  difficult  to  suc- 
ceed in  breaking  the  bone  in  the  direction  1  wished, 
and,  after  a  great  number  of  experiments,  was  suc- 
cessful only  in  the  following  instances;  the  prepara- 


OF  THE  THIGH-BONE. 


149 


tions  of  these  I  have  preserved,  and  they  may  be 
seen  in  the  Museum  at  St  Thomas's  Hospital.  (See 
Plate.) 


Experiment  I. 

The  neck  of  the  thigh-bone  was  fractured  in  a 
rabbit,  on  October  28th,  1818;  and  on  December 
1st,  1818,  as  the  wound  had  been  some  tin)e  healed, 
I  dissected  the  animal. 

Jlppearance  on  dissection. —  The  capsular  ligament 
was  much  thickened;  the  head  of  the  bone  was 
entirely  disunited  from  its  neck,  but  adhered  by  a 
new  ligamentous  substance  to  the  capsular  ligament  ; 
the  broken  cervix,  which  was  very  much  shortened, 
played  on  the  head  of  the  bone,  and  had  smoothed 
it  by  attrition;  the  head  of  the  thigh-bone  had  not 
undergone  any  ossific  change. 


Experiment  IL 

The  neck  of  the  thigh-bone  was  broken  in  a  dog, 
November  18th,  1818,  and  the  animal  was  killed  on 
the  14th  of  December  following. 

Dissection.  —  The  trochanter  was  much  drawn  up 
by  the  action  of  the  muscles,  so  that  the  head  and 
cervix  femoris  were  not  in  apposition.  The  capsu- 
lar ligament  was  much  thickened,  and  contained  a 
large  quantity  of  synovia. 

The  joint  was  lined  with  adhesive  matter  of  a 
ligamentous  appearance,  adhering  to  the  head  of 
the  bone,  which  did  not  seem  to  be  changed  by  any 
ossific  process;  but  the  thigh-bone  around  the  cap- 


150 


FRACTURES  OF  THE  UPPER  PART 


sular  ligament,  the  trochanter  major,  and  the  bone 
a  httle  below  it,  were  enlarged.  . 

We  find,  therefore,  by  these  dissections,  that 
what  appears  in  the  human  subject  after  this  acci- 
dent, takes  place  also  in  other  animals;  and  that 
motion,  want  of  apposition  and  pressure,  with  the 
little  ossific  action  in  the  head  of  the  bone,  under 
these  circumstances,  produce  a  deficiency  of  bony 
union,  as  in  man. 

Tlie  two  preparations  which  I  have  preserved, 
were  the  only  examples  in  which  the  experiment 
was  complete  in  relation  to  the  transverse  fracture  ; 
but  I  [lave  two  other  interesting  preparations  deriv- 
ed from  these  experiments.  I  also  made  a  great 
number  of  others,  in  wliich  the  fractures  continued 
com[)ound;  in  each  of  these  the  head  of  the  bone 
either  became  absorbed,  or  was  discharged  by  ulcer 
ation;  and  I  never  could  succeed  in  uniting  the 
head  to  the  neck  of  the  bone.  I  have  since  divid- 
ed the  neck  of  the  thigh-bone  in  a  dog,  and  the 
head  of  the  bone  was  three-fourths  absorbed.  By 
way  of  contrast,  I  have  also  divided  the  bone  ex- 
ternally to  the  capsule,  in  five  instances,  and  have 
preserved  the  bones;  the  wounds  united  by  adhe- 
sion, and  every  bone  has  been  healed  by  ossific 
union;  the  natural  inference  is,  that  fractures  within 
the  capsule  are  not  at  all  susceptible,  but  that  frac- 
tures external  to  it  are  readily  susceptible  of  union 
by  bone.  As  to  the  notion  that  tlie  bearing  upon 
the  limb,  or  its  weight,  may  have  influence  to  pre- 
vent union  in  these  animals,  I  have  only  to  observe, 
that  the  muscles  become  contracted,  the  limb  is 
drawn  up,  and  the  animal  cannot  bear  upon  it  for 
several  weeks. 


OF  THE  THIGH-BONE. 


151 


My  friend,  Mr  Brodio,  has  furnished  me  with  the 
following  account  of  an  experiment  which  he  made 
upon  the  ^ame  subjecl,  wliicii  fully  conhrins  mj  ob- 
servations. 

Dear  Sir:  —  The  circumstances  of  the  experi- 
ment which  I  mentioned,  were  briefly  these.  The 
tibia  of  a  guinea-[)ig  was  broken  at  the  lower  end. 
A  month  afterwards  the  animal  was  killed.  On  dis- 
section, I  found  a  IVacrure  extending  across  the  tibia, 
transversely,  and  so  close  to  the  ankle-joint,  that  it 
was  situated  at  that  part  of  the  bone  which  is  cov- 
ered bj  the  reflected  layer  of  the  synovial  mem- 
brane. The  synovial  membrane  itself,  and  the  liga- 
ments of  the  joint,  appeared  to  have  been  very  little 
injured,  and  the  broken  surfaces  had  remained  in 
good  apposition;  nevertheless,  there  was  not  the 
smallest  union  of  them,  either  by  bone  or  liganient, 
and  there  had  been  no  formation  of  callus  round- the 
fracture.  The  bone  in  the  neighbourhood  of  the 
fracture  had  become  compact  and  hard,  in  conse- 
quence of  the  ossification  of  the  medullary  membrane 
lining  the  cancelli. 

I  am,  dear  Sir,  your's  truly, 
Saville  Row ;  B.  C.  Brodie. 

August  mh,  1823, 

Professor  Burns,  of  Glasgow,  has  had  the  great 
kindness  to  send  me  the  following  observations. 

Permit  me  to  offer  my  warmest  thanks  for  the 
pleasure  and  edification  I  have  received  from  the 
study  of  your  late  work.  I  was  early  led  to  attend 
to  the  process  adopted  by  nature  in  forming  a  new 
articulation  in  injuries  to  the  hip-joint,  by  the  dissec- 
tion of  a  dog  which  I  had  when  a  boy,  and  which 
had  the  hip  fractured.    Many  years  afterwards  1 


152  FRACTURES  OF  THE  UPPER  PART 


examined  the  parts,  and  found  the  fragment  of  the 
cervix  belonging  to  the  head  absorbed,  the  head  it- 
self filling  the  acetabulum  ;  the  shaft  of- the  bone 
expanded  ;  a  new  head  formed  for  a  new  socket, 
and  the  whole  enveloped  in  a  dense  capsule  or  cov- 
ering. 

In  a  fracture  of  the  os  femoris  external  to  the 
capsule,  the  gluteus  medius  and  minimus  seem  to  act 
as  a  cushion  to  stop  the  ascent  of  the  end  of  the  cer- 
vix, whilst  the  fragment  attached  to  its  head  will, 
perhaps,  atford  some  opposition  ;  but  in  the  fracture 
within  the  ca[)sule,  the  end  of  the  cervix  is  drawn 
more  freely  up  under  the  gluteus  medius,  and  lodged 
behind  the  inferior  spinous  process  of  the  ilium. 

Is  this  the  explanation  of  the  greater  shortening 
in  the  one  fracture  than  in  the  other? 

Nothing  can  better  explain  the  want  of  ossific 
union  than  the  principle  you  have  laid  down. 

John  Burns. 

Glasgow,  1823. 

Having  by  experiment  verified  the  results  I  have 
mentioned,  1  was  next  anxious  to  learn  if  the  head 
and  neck  of  the  thigh-bone  would  unite  under  a  lon- 
gitudinal fracture,  partly  within  and  partly  external 
to  the  capsular  ligament,  in  which  apposition,  contact 
and  pressure,  are  maintained  ;  and  for  this  purpose 
1  made  the  following  experiment. 

Experiment  IIL 

Longitudinal  fracture,  —  I  divided  the  head,  neck, 
and  a  portion  of  the  trochanter  major  of  the  thigh- 
bone of  a  dog  longitudinally,  by  placing  a  knife  on 
the  trochanter  major,  and  striking  it  down  towards 


OF  THE  THIGH-BONE. 


153 


the  acetabulum  through  the  head  of  the  bone.  The 
animal  was  killed  twenty-nine  days  after,  and  the 
following  appearances  presented  themselves. 

A  portion  of  the  trochanter  major  had  been  bro- 
ken off,  and  was  only  united  by  cartilage.  The 
head  and  neck  of  the  bone,  which  had  been  longi- 
tudinally broken,  were  united  ;  the  neck  by  a  larger 
quantity  of  ossific  deposit  than  that  which  joined  the 
separated  portions  of  the  head  of  the  bone,  and  so 
irregularly  as  to  make  a  beautiful  preparation,  and 
show  the  circumstance  most  clearly.  (See  Plate.) 
This  bone  may  be  seen  in  the  collection  at  St 
Thomas's  Hospital. 

Whether  the  union  began  in  the  fracture  exter- 
nally to  the  ligament,  and  proceeded  inwards,  or 
whether  on  the  whole  surface  at  once,  it  is  impos- 
sible to  ascertain ;  but  the  coalescence  was  firm, 
though,  as  I  have  stated,  I  thought  more  so  at  the 
neck  than  at  the  head  of  the  bone.  The  union  in 
this  case  is  readily  explained.  Apposition  was  sup- 
ported; the  vessels  of  the  head  of  the  bone  and 
cervix  remained  whole  ;  and,  therefore,  this  experi- 
ment shows  at  once  why  the  longitudinal  unites,  and 
the  transverse,  in  general,  does  not  unite. 

Union  of  these  bone^.  —  Thus  then,  it  appears,  that 
in  a  longitudinal  fracture  of  the  head  and  neck  of 
the  bone  partly  external  to  the  ligament^  if  the  bones 
be  applied  to  each  other,  pressed  together,  and  in  a 
state  of  rest,  and  the  vessels  remain,  ossific  union  can 
be  produced;  although  the  ossific  deposition  is  ex- 
tremely slight  when  compared  with  that  of  other 
bones. 

Diagnosis. — The  fracture  of  the  neck  of  the 
thigh-bone  may  be  confounded  with  the  dislocation 
of  the  OS  femoris  upon  the  dorsum  ilii ;  with  that  into 
the  ischiatic  notch;  and  with  that  upon  the  pubes ; 
20 


154  FRACTURES  OF  THE  UPPER  PART 


as  in  all  these  luxations  the  limb  is  shorter.  From 
the  two  former  it  may  be  distinguished  by  the  ever- 
sion  of  the  foot,  and  by  the  mobility  of  the  limb  in 
fracture  ;  and  from  the  latter  by  the  ball  of  the  os 
femoris  being  felt  in  the  groin  in  the  dislocation  on 
the  pubes ;  otherwise  the  eversion  of  the  foot  in 
both  cases  might  lead  to  their  being  confounded. 

Treatment.  —  With  respect  to  the  treatment  of 
fractures  of  the  neck  of  the  thigh-bone  within  the 
capsular  ligament,  various  are  the  means  to  which  1 
have  had  recourse,  and  which  I  have  known  resort- 
ed to  by  others,  for  the  purpose  of  producing  union 
in  this  accident,  but  all  without  avail. 

One  mode  has  consisted  in  placing  the  fractured 
limb  over  a  double  inclined  plane,  thus  maintaining 
a  regular  and  constant  extension,  which,  by  raising 
the  planes  at  the  knee,  may  be  increased  to  any  de- 
gree that  the  surgeon  may  require,  or  the  patient 
can  bear ;  at  the  same  time,  a  bandage  is  applied 
around  the  pelvis  and  upper  part  of  the  thigh,  to 
bring  the  neck  of  the  bone,  as  much  as  possible,  in 
approximation  with  the  head  from  which  it  has 
been  separated;  and  this  extension,  with  pressure, 
has  been  steadily  preserved  for  three  months.  With 
respect  to  the  patient's  body,  it  has  been  placed  at 
an  angle  of  forty-five  degrees. 

A  second  method  has  consisted  in  placing  a  board 
at  the  foot  of  the  bed,  upon  which  the  foot  of  the 
sound  limb  rested,  so  as  to  prevent  the  descent  of 
the  body  in  the  bed  ;  the  other  limb  was  then  ex- 
tended as  much  as  possible,  and  a  weight,  appended 
to  the  foot,  was  suffered  to  hang  through  a  hole  in 
the  board  over  the  end  of  the  bed,  in  order  to  sup- 
port the  extension  with  regularity  and  steadiness  for 
several  weeks. 

In  a  third  method,  the  patient  has  been  placed  in 
bed  with  both  limbs  extended  to  the  utmost  possible 


OF  THE  THIGH-BONE. 


155 


degree,  and  then  the  two  feet  have  been  bound  to- 
gether by  a  roller,  passed  from  the  foot  on  the  in- 
jured side  under  the  sound  foot,  so  as  to  make  one 
Jimb  steadily  preserve  the  extension  of  the  other. 
This  may  also  be  effected  by  an  iron  plate  affixed  to 
the  shoe  on  the  sound  foot,  with  a  screw  passed 
through  a  hole  in  the  plate,  and  having  a  band  fixed 
to  the  other  foot,  which  may  be  tightened  by  turn- 
ing the  screw,  and  the  foot,  by  this  means,  be  kept 
constantly  extended. 

A  fourth  mode  employed  for  this  purpose  has 
been  the  application  of  Boyer's  splint,  with  the  in- 
tention of  extending  the  limb  from  the  pelvis;  but 
this  splint,  though  it  answers  well  for  fractures  of 
the  thigh  under  ordinary  circumstances,  has  a  ten- 
dency to  prevent  union  in  those  fractures  which  oc- 
cur at  the  upper  part  of  the  bone,  by  the  pressure 
of  its  band  upon  the  inner  and  upper  portion  of  the 
thigh. 

Mr  Hagedorn  has  recommended  a  machine  for 
fractures  of  the  neck  of  the  thigh-bone,  which  is  very 
ingenious  in  its  construction.  It  consists  of  a  long 
splint  to  extend  from  the  hip  to  the  foot,  and  to  be 
firmly  applied,  by  means  of  proper  straps,  to  the 
sound  limb;  at  the  bottom  of  this  is  fixed  a  broad 
foot-board,  perforated  with  a  sufficient  number  of 
openings  to  receive  the  bands,  by  means  of  which 
both  feet  are  to  be  securely  fixed  to  it ;  these  band- 
ages are  attached  to  a  kind  of  leathern  gaiter,  made 
to  lace  tight  round  the  ankle,  and  the  upper  part  of 
the  splint  is  kept  close  to  the  hip  by  means  of  a 
broad  bandage  carried  round  the  pelvis.  By  this 
machine  the  extension  of  the  limb  is  tolerably  well 
effected,  so  long  as  the  patient  can  be  kept  still; 
but  a  displacement  of  the  bones  will  invariably  be 
the  consequence  of  every  motion  which  the  evacua- 
tion of  the  faeces  will  necessarily  require.    I  am 


156 


FRACTURES  OF  THE  UPPER  PART 


never  so  wedded  to  any  opinion  as  to  be  prevented 
from  trying,  or  from  wishing  others  to  employ,  every 
means  which  appear  plausible  or  ingenious;  and, 
therefore,  I  think  that  this  instrument  ought  to  have 
a  fair  trial. ^ 

Mr  Earle  is  of  opinion,  that  these  cases  may  be 
cured  by  long  continued  attention  in  keeping  the 
parts  at  perfect  rest,  I  think  a  trial  should  be  made 
of  the  bed  recommended  by  Mr  Earle,  and  heartily 
wish  him  success  in  his  laudable  attempt  to  prevent 
the  lameness  and  shortening  of  the  limb  in  cases  of 
fracture  within  the  capsule  ;  which  has  invariably 
been  the  result  in  those  cases  which  I  have  had  an 
opportunity  of  observing. 

But  all  the  means  which  I  have  seen  used  have 
been  found  unavailing.  I  have  been  baffled  at  every 
attempt  to  cure,  and.  have  not  yet  witnessed  one 
single  example  of  union  in  this  fracture.  I  know 
that  some  persons  still  believe  in  the  possibility 
of  this  union,  by  surgical  treatment,  and  that  instan- 
ces of  success  have  been  published  ;  but  I  cannot  give 
credence  to  such  cases  until  I  see  that  the  authors 
were  aware  of  the  distinction  between  fractures 
within  and  fractures  external  to  the  articulation. 

The  following  anecdote  was  related  to  me  by  an 
intelligent  surgeon,  who  had  been  attending  an  hos- 
pital on  the  Continent  for  some  time.  One  of  the 
surgeons  belonging  to  it  observed,  '  Some  of  the 
English  surgeons  do  not  believe  that  we  unite  frac- 
tures of  the  neck  of  the  thigh-bone  ;  now  there  is 
one  that  you  shall  examine,  as  the  patient  is  dying.' 
A  few  days  after,  the  patient  died,  and  the  joint  was 

*  For  a  modification  of  Hagedorn's  apparatus  by  Professor 
Gibson,  and  an  ingenious  application  of  the  single  inclined  plane, 
see  the  Philadelphia  Journal  of  the  Medical  and  Physical  Scien- 
ceSj  and  the  1st  vol.  of  Gibson's  Surgery.  J.  P.  G, 


OF  THE  THIGH-BONE. 


157 


examined,  when  the  bone  was  found  stiH  disunited. 
The  surgeon  of  the  hospital  only  made  a  significant 
shrug  of  disappointment. 

The  cases  in' which  union  might  be  produced  are 
two  :  one,  in  which  the  periosteum  covering  the 
neck  of  the  thigh-bone  is  not  torn  through,  a  cir- 
stance  which  now  and  then  happens;  the  other,  in 
which  the  head  of  the  bone  is  broken,  so  that  the 
cervix  still  remains  in  the  acetabulum:  but  in  neither 
of  these  cases  will  the  limb  exhibit  the  shortened 
state  which  the  fracture  of  the  neck  of  the  bone 
usually  produces,  and,  therefore,  the  common  cha- 
racters of  the  accident  will  be  wanting.  Even  in 
such  cases,  I  would,  in  consideration  of  the  confine- 
ment and  danger  of  bony  union,  prefer  a  ligamentous 
union,  as  well  from,  regard  to  the  health  and  life  of 
the  person,  as,  I  believe,  to  the  subsequent  use  of 
the  joint. 

The  various  attempts  at  curing  these  cases  having 
failed,  and  the  patients'  health  having  invariably  suf- 
fered under  the  trials  made  to  effect  union,  1  should, 
if  I  sustained  this  accident  in  my  own  person,  direct 
that  a  pillow  should  be  placed  under  the  limb 
throughout  its  length;  that  another  should  be  rolled 
up  under  the  knee,  and  that  the  limb  should  be  thus 
extended  for  ten  days  or  a  fortnight,  until  the  inflam- 
mation and  pain  had  subsided.  1  should  then  daily 
rise  and  sit  in  a  high  chair,  in  order  to  prevent  a 
degree  of  flexion,  which  would  be  painful;  and, 
walking  with  crutches,  bear  gently  on  the  foot  at 
first ;  then,  gradually  more  and  more,  until  the  liga- 
ment became  thickened,  and  the  muscles  increased 
in  their  power.  A  high-heeled  shoe  should  be  next 
employed,  by  which  the  halt  would  be  much  dimin- 
ished. Our  hospital  patients,  treated  after  this  man- 
ner, are  allowed  in  a  few  days  to  walk  with  crutches; 
after  a  time  a  stick  is  substituted  for  the  crutches, 


158 


FRACTURES  OF  THE  UPPER  PART 


and  in  a  few  months  they  are  able  to  use  the  limb 
without  any  adventitious  support. 

The  degree  of  recovery  in  these  cases  is  as  fol- 
lows:—  if  the  patient  be  very  corpulent,  the  aid  of 
crutches  will  be  for  a  long  time  required;  if  less 
bulky,  a  stick  only  will  be  sufficient ;  and  where  the 
weight  of  the  body  is  inconsiderable,  the  person  will 
be  able  to  walk  without  either  of  these  aids,  but 
will  drop  a  little  at  each  step  on  that  side,  unless  a 
shoe  be  worn  having  a  sole  of  equal  thickness  to 
the  diminished  length  of  the  limb.  In  every  case, 
however,  in  which  there  is  the  smallest  doubt 
whether  it  be  a  fracture  within,  or  external  to  the 
ligament,  it  will  be  proper  to  treat  the  case  as  if  it 
were  the  fracture  which  I  shall  hereafter  describe, 
and  which  admits  of  ossific  union. 

It  is  gratifying  to  find  opinions  which  have  been 
for  thirty  years  delivered  in  my  lectures,  confirmed 
by  the  observations  of  intelligent  and  observing  per- 
sons ;  and,  therefore,  it  was  with  pleasure  that  I 
read  in  the  Dublin  Hospital  Reports,  the  account  of 
the  dissection  of  several  cases  of  fracture  of  the  cer- 
vix femoris,  by  my  friend,  Mr  CoUes,  of  Dublin,  (a 
man  excellently  informed  in  his  profession)  who 
found  in  them  similar  want  of  ossific  union,  in  the 
fracture  within  the  ligament,  to  that  which  I  have 
described.  A  few  contributions  of  a  similar  kind, 
from  the  ardent  cultivators  of  morbid  anatomy, 
would  soon  prevent  persons  from  being  tortured 
with  trials,  which  have  been  frequently  repeated, 
and  found  to  be  uniformly  unavailing, 


OF  THE  THIGH-BONE. 


159 


ADDITIONAL  OBSERVATIONS  ON  FRACTURES  OF  THE 
NECK  OF  THE  THIGH-BONE. 

The  following  letters,  which  were  appended  to 
the  former  editions  of  this  work,  merit  a  permanent 
record;  each  of  them  being  interesting  in  regard  to 
the  facts  upon  this  subject.  One  is  from  Mr  Stan- 
ley, Assistant-Surgeon  of  Saint  Bartholomew's  Hos- 
pital, and  Demonstrator  of  Anatomy  at  that  hospital; 
one  from  Dr  Monro,  Professor  of  Anatomy  at  Edin- 
burgh ;  and  the  other  from  Mr  CoUes,  Professor  of 
Anatomy  and  Surgery  at  Dublin. 

Lincoln'^ s  Inn  Fields^  February  25th,  1823. 

My  dear  Sir:  —  We  have  in  the  Museum  of  St 
Bartholomew's,  twelve  specimens  of  fractures  in 
the  neck  of  the  thigh-bone;  six  external  to  the 
capsule,  and  united,  and  six  within  the  capsule.  In 
three  of  the  latter  there  is  no  union,  and  in  the 
other  three  there  is  union  by  ligamentous  matter. 
I  remain,  dear  Sir, 

Yours  most  respectfully, 
Edward  Stanley. 


This  letter  shows  the  difference  of  fractures 
within  and  fractures  external  to  the  ligaments,  in 
regard  to  their  union. 

Edinburgh,  February  \lth,  1823. 

Mr  dear  Sir  Astley  :  —  In  answer  to  jour  query 
respecting  fracture  of  the  neck  of  the  thigh-bone,  I 
beg  leave  to  inform  you,  that  I  have  had  an  oppor- 


160 


FRACTURES  OF  THE  UPPER  PART 


tunity  of  examining  two  cases  only  after  death,  and 
in  both  of  these,  the  broken  ends  of  the  neck  of 
the  bone  were  united  by  a  substance  somewhat  like 
to  ligament. 

I  have  seen  several  persons  who  had,  during  their 
lives,  a  fracture  of  the  neck  of  the  bone,  but  in  all 
of  them  a  bony  reunion  had  not  taken  place. 

In  the  catalogue  of  the  Museum  which  was  be- 
queathed.to  the  University  by  my  father,  mention  is 
made  of  the  fracture  of  the  neck  of  the  thigh-bone 
which  had  re-united  by  a  bony  union.  Upon  exam- 
ining the  preparation  with  attention,  it  appears  to 
me,  that  there  has  been  no  fracture,  but  a  disease  in 
the  trochanter  major,  and  that  a  number  of  osseous 
speculoe  have  shot  upwards  within  the  capsular 
ligament,  giving  the  appearance  of  an  ill-set  fracture. 

Should  you  wish  to  have  a  drawing  of  this  pre- 
paration, I  shall  have  great  pleasure  in  sending  it 
to  you. 

There  is  also  a  specimen  in  the  Museum  of  a 
fracture  of  the  thigh,  about  four  lines  beyond  'the 
insertion  of  the  capsular  ligament,  at  the  root  of 
the  trochanter. 

Your's  most  truly, 

Alexander  Monro. 


Stephen^ s  Green,  February  12^/^,  1823. 
My  dear  Sir:  —  Since  the  receipt  ot"  y6ur  letter, 
1  have  carefully  examined  all  the  specimens  of 
fractures  of  the  neck  of  the  thigh-bone  contained 
in  both  Museums  of  our  College  of  Surgeons.  In 
that  which  is  appropriated  to  the  use  of  the  School, 
I  find  seven  instances  of  fracture  within  the  liga- 
ment;  each  of  these  has  been  described  in  my 
paper  on  this  subject,  in  the  Dublin  Hospital  Re- 
ports.    Since  the  publication  of  that  Essay,  the 


OF  THE  THIGH-BONE. 


161 


conservator  of  the  College  Museum  has  collected 
live  Sjiecimens  of  fracture  within  the  ligament.  In 
this  Museum  are  also  four  instances  of  fracture  ex- 
teinal  to  the  condyle  ligament.  In  the  School 
Museum  are  two  instances  of  fracture  external  to 
the  ligament.  Of  this  latter  description  of  fracture, 
fewer  than  one  half  the  number  are  united  by  bony 
union.  Of  the  fractures  within  the  ligament,  not 
one  has  made  a  nearer  approach  to  bony  union  than 
that  described  in  the  paper  alluded  to.  I  must  say, 
that  1  have  never  yet  seen  an  instance  of  bony 
union  where  the  fracture  had  been  within  the  liga- 
ment. We  have  very  many  specimens  of  a  disease 
of  the  head  and  neck  of  the  thigh-bone,  which  is 
of  frequent  occurrence  amongst  our  labouring  poor. 
On  this  subject  1  have  some  idea  of  writing  a  paper 
for  the  next  volume  of  the  Dublin  Hospital  Reports, 
and  of  endeavouring  to  show,  that  in  all  probability, 
the  supposed  cases  of  fracture  within  the  ligament 
united  by  bone,  were  merely  instances  of  this 
disease. 

If  you  have  any  wish  for  them,  I  shall  have  great 
pleasure  in  sending  you  sections  of  some  of  these 
cases,  which  I  am  certain  might  be  passed  upon  many 
surgeons  for  fracture  of  the  neck  of  the  bone.  . 

I  am,  my  dear  Sir, 

Your  sincere  friend, 

A.  COLLES. 


I  have  also  seen  three  cases  of  this  fracture  in 
the  dead  body  since  the  publication  of  the  second 
edition  of  this  work. 

First  ;  —  A  very  old  female  was  brought  into  the 
dissecting-room  at  St  Thomas's  Hospital,  whos  ;  right 
limb  was  everted,  and  was  an  inch  and  a  half  shorter 
than  the  left.    Upon  dissection,  the  sciatic  nerve 

21 


162 


FRACTURES  OF  THE  UPPER  PART 


had  the  appearance  of  having  been  bruised  ;  a  small 
portion  of  bone  was  broken  off  at  the  Insertion  of  the 
obturator  externus  muscle  ;  a  similar  portion  of  bone 
was  separated  at  the  upper  part  of  the  Insertion  of 
the  quadratus  femorls.  The  capsular  ligament  was 
torn  at  the  part  at  which  it  is  covered  by  the  iliacus 
internus  muscle.  The  capsular  ligament  being  further 
opened,  was  found  to  contain  a  small  fragment  of 
bone ;  and  it  was  filled  with  adhesive  ligamentous 
matter,  poured  out  bj  Inflammation,  and  adhering 
to  the  internal  surface  of  the  capsular  ligament,  to 
the  remnants  of  the  cervix  femoris,  and,  slightly,  to 
the  head  of  the  bone.  The  cervix  femoris  had  been 
broken  close  to  the  head  of  the  bone,  and  entirely 
within  the  capsular  ligament.  The  head  of  the  fe- 
mur remained  in  the  acetabulum  unaltered,  except- 
ing that  its  surface  was  partially  covered  by  liga- 
ment. The  neck  of  the  bone  was  so  absorbed,  that 
the  portion  of  it  which  remained  was  smaller  than 
the  trochanter  minor.  Its  cancellated  structure  was 
covered  by  the  effused  ligamentous  matter.  There 
was  not  the  slightest  appearance  of  ossific  union,  or 
even  of  bony  deposit,  although  this  injury  must,  from 
the  changes  produced  by  inflammation,  have  hap- 
pened from  two  to  three  months  before  death. 
When  I  had  raised  the  thigh-bone  one  inch  and  a 
half,  it  was  prevented  from  rising  higher  by  the 
lower  portion  of  the  gluteus  minimus,  and  by  the 
capsular  ligament. 

Second:  —  Mr  Clarke  gave  me  a  preparation 
made  from  the  body  of  a  man,  eighty-two  years  of 
age,  tall  and  remarkably  strong  for  the  time  of  life, 
who  died  eight  weeks  and  four  days  after  having 
fractured  the  neck  of  the  thigh-bone.  Upon  inspec- 
tion, not  the  least  attempt  at  ossific  union  was  found. 
The  ligamentous  sheath  of  the  cervix  femoris  was 
only  partially  torn. 


OF  THE  THIGH-BONE.  163 


Third  :  —  Mr  Key,  surgeon  to  Guy's  Hospital, 
gave  me  the  head  and  neck  of  the  thigli-bone,  taken 
from  a  subject  brought  into  the  dissecting-room  ;  in 
which  case,  the  neck  of  the  thigh-bone  was  absorb- 
ed. The  head  of  the  thigh-bone  was  entirely  de- 
tached from  the  cervix.  No  ossific  process  existed 
in  the  cancelli  of  either  the  neck  or  head  of  the 
bone,  but  some  ossific  deposit  appeared  around  the 
insertion  of  the  ligamentum  teres. 

1  have  a  patient  in  Guy's  Hospital  at  this  time, 
with  a  fracture  of  the  neck  of.  the  thigh-bone,  in 
whom  the  following  circumstances  are  to  be  observ- 
ed: —  When  placed  in  the  recumbent  posture,  the 
limb  is  one  inch  and  a  half  shorter  than  the  other  ; 
but  when  he  is  standing,  the  injured  limb  is  two 
inches  and  a  half  shorter  than  the  sound  limb  :  the 
cause  of  this  contrariety  is  as  follows:  When  he  is 
recumbent,  and  the  spinous  processes  of  the  ilia  are 
in  the  same  line,  the  shortening  is  only  from  the  re- 
traction of  the  thigh-bone;  but  when  he  is  standing, 
he  throws  the  axis  of  his  body  into  the  thigh  of  the 
soundJimb,  to  enable  him  to  support  himself ;  and 
elevating  the  pelvis,  raises  the  injured  limb  one  inch 
more  than  when  he  is  recumbent. 


FRAClrURES  OF  THE  CERVIX  FBMORIS  EXTERNAL  TO  THE 
CAPSULAR  LIGAMENT,  AND  INTO  THE  CANCELLI  OF  THE 
TROCHANTER  MAJOR. 

The  symptoms  of  this  accident  in  some  respects 
resemble  those  of  the  fracture  within  the  ligament, 
and  they  require  much  attention  to  distinguish  them 
accurately;  but  the  result  is  entirely  different;  so 
that  a  favourable  opinion  may  be  given  as  to  the 
restoration  of  the  bone  by  an  ossific  union. 


164 


FRACTURES   OF  THE  UPPER  PART 


Symptoms,  —  In  this  accident,  the  Injured  leg  is 
shorter  than  the  other  by  one  half  to  three  quarters 
of  an  inch  ;  the  foot  and  toe  on  that  side  are  evert- 
ed, from  the  loss  of  support  which  the  body  of  the 
thigh-bone  sustains  in  consequence  of  the  fracture.; 
much  pain  is  felt  at  the  hip,  and  on  the  inner  and 
upper  part  of  the  thigh  ;  and  the  joint  loses  its 
usual  roundness. 

Diagnostic  marks;  union  of  the  hone,  —  The  dis- 
tinguishing signs  of  this  accident  are,  — First  :  —  It 
sometimes  occurs  at  the  earlier  periods  of  life  ;  for 
it  happens  In  the  young,  and  in  the  adult  under  fifty 
years  of  age,  although  I  have  known  it  at  a  later 
period,  when  it  often  proves  fatal ;  but  if  the  above 
symptoms  are  seen  at  any  age  under  fifty  years^  there 
will  be  generally  found  a  fracture  external  to  the 
capsular  ligament,  and  capable  of  ossific  union.  Sev- 
eral of  these  cases  which  have  fallen  under  my  no- 
tice  have  occurred  under  that  period  ;  and,  there- 
fore, a  surgeon  called  to  the  bed-side  of  a  patient 
who  has  an  injury  to  the  upper  part  of  the  thigh- 
bone, if  he  finds  the  age  of  the  patient  to  be  under 
fifty  years,  will,  with  very  few  exceptions,  be  war- 
ranted in  pronouncing  it  either  a  fracture  just  ex- 
ternal to  the  ligament,  or  one  through  the  trochanter 
major.  But  I  also  mention  that  both  fractures  occur 
in  age,  and  therefore  no  discrimination  can  be  drawn 
between  the  two,  in  advanced  age,  but  by  the  most 
careful  examination. 

From  severe  injuries,  —  Secondly  : —  These  cases 
may  be  in  some  measure  distinguished  by  the  seve- 
rity of  the  accident  which  produces  them;  for 
whilst  the  internal  fracture  happens  from  very  slight 
causes,  this,  on  the  contrary,  is  produced  either  by 
severe  blows,  or  falls  upon  the  edge  of  some  pro- 
jecting body,  as  against  the  edge  of  the  curb-stone, 
or  from  the  pressure  of  laden  carriages  passing  over 


OF  THE  THIGH-BONE. 


the  pelvis.  My  experience  has  taught  me,  that  a 
very  shght  accident  generally  occasions  tlie  fracture 
within  the  capsule,  and  a  violent  blow  or  tail,  the 
other;  the  first  is  an  accident  upon  which  the  fall 
often  succeeds,  the  other  is  generally  the  conse- 
quence of  that  fall.  Many  of  those  within  the  caj)- 
sule  which  I  have  witnessed,  were  produced  by  the 
person's  slipping  from  the  curb-stone  to  "the  road- 
way;"* not  that  I  mean  to  deny,  that  a  fall  will,  and 
do6s  occasionally,  produce  a  fracture  within  the 
capsule,  or  that  in  a  very  old  person,  a  fracture  may 
occasionally  happen  in  any  part  of  a  bone,  from  a 
slight  cause  compared  ^vith  that  which  produces  it 
in  the  young. 

Crepitus,  — Thirdly  :  —  It  may  be  generally  known 
by  the  crepitus  which  attends  it  upon  slight  motion  ; 
and  so  small  is  the  retraction,  that  it  is  unnecessary 
to  draw  down  the  limb  to  distinguish  the  grating  of 
one  bone  upon  the  other. 

Fourthly  :  —  Great  ecchymosis  often  attends  it. 

Swelling.  —  Fifthly  :  —  Swelling  and  tenderness 
to  the  touch  quickly  succeed  upon  the  upper  part 
of  the  thigh,  from  the  inflaaimation  which  this  in- 
jury produces. 

Severe  pain.  —  Sixthly  : —  This  accident  is  gener- 
ally marked  by  much  greater  severity  of  sutfering 
than  the  fracture  within  the  ligament,  slight  motion 
producing  excruciating  pain,  which  does  not  happen 
in  an  equal  degree  in  the  fracture  within  the 
liga-ment. 

Seventhly  :  —  There  is  a  high  degree  of  irrita- 
tive fever,  and  many  months  elapse  before  the  pa- 
tient recovers  any  use  of  his  limb. 

*  Slipping  from  the  ciirb-stone  to  the  road-way  produces  a 
violence  in  the  perpendicular  direction  ;   falling  against  the 
edge  of  the  curb-stone  often  produces  the  fracture  external  to  * 
the  capsule. —  A.  C. 


166 


FRACTURES   OF  THE   UPPER  PART 


Dissection. — Upon  dissection  of  these  cases,  the 
seat  of  the  fracture  is  found  to  vary  very  much  in 
different  examples,  being  more  or  less  complicated, 
but  it  is  external  to  the  capsular  ligament;  and  the 
fracture  is  placed  at  the  neck  of  the  root  of  the 
thigh-bone,  the  trochanter  is  sp)lit,  and  the  neck  of 
the  bone  is  received  into  its  cleft.  The  trochanter 
major  is  often  broken  into  several  portions. 

We  have  few  opportunities  of  dissecting  these 
cases  in  the  young,  because  they  recover  from  the 
accident ;  and,  therefore,  the  examination  of  them 
has  been  most  frequently  made  in  aged  persons,  to 
whom  they  often  prove  fatal.  The  following  cases 
will  explain  the  appearances  on  dissection. 

Mr  Powell,  surgeon,  of  Great  Coram  Street,  pre- 
sented me  with  a  valuable  preparation,  taken  from 
a  patient  of  his  who  died  fifteen  months  after  the 
accident,  and  the  following  is  the  history  of  the 
case. 


Fracture  of  the  JVeck  of  the  Thigh-Bone, 

Case,  —  Mary  Clements,  aged  eighty-three  and  a 
half  years,  when  walking  across  her  room,  October 
1st,  1820,  supported  by  her  stick,  which  from  the 
debility  consequent  upon  old  age  she  was  obliged  to 
employ,  unperceived  by  herself,  placed  her  stick  in 
a  hole  of  the  floor,  by  which,  losing  her  balance,  and 
tottering  to  recover  herself  from  falling,  which  she 
would  have  done  but  for  those  near  her,  she  found 
she  had,  as  she  supposed,  dislocated  her  thigh-bone. 
When  called  to  her,  she  was  lying  upon  her  bed,  in 
much  pain,  with  the  thigh  shortened,  and  the  foot 
everted.  Suspecting  the  nature  of  the  accident,  I  di- 
rected extension  to  be  made  by  the  foot,  which  I 
found  was  readily  brought  to  correspond  with  the 


OF  THE  THIGH-BONE. 


167 


opposite  side  ;  and  upon  rotating  the  llrnb  I  discov- 
ered a  crepitus,  which  fully  confirmed  me  in  the 
opinion  that  some  part  of  the  neck  of  the  femur  was 
broken.  With  a  view  to  the  union  of  the  bone,  I 
first  placed  the  limb  in  a  straight  position,  making  a 
permanent  extension  by  fixing  the  pelvis  and  extend- 
ing from  the  ankle  ;  but  as  the  mental  faculties  were 
nearly  as  much  shaken  as  the  corporeal,  and  she 
could  not  be  induced  to  keep  up  the  extension  re- 
quired,! was  obliged  after  a  few  days  to  change  my 
plan  for  that  of  two  boards  united  together  at  right 
angles,  over  which  the  thigh  was  placed,  and  was 
supported  by  pillows  kept  in  their  position  by  later- 
al pegs.  In  a  very  few  days  this  position,  in  which 
she  at  first  expressed  herself  comfortable,  became 
so  irksome,  that  she  would  no  longer  submit  to  it, 
and  I  was  obliged  again  to  abandon  my  wish  to  be 
decidedly  uselul  to  her.  From  this  period  she 
adopted  any  position  that  was  most  comfortable  to 
herself,  but  generally  as  the  easiest  state,  lay  upon 
the  same  side  as  the  accident,  with  the  limb  drawn 
up  at  nearly  right  angles  with  the  body.  The  neigh- 
bourhood of  the  joint,  in  the  early  stage  of  the  acci- 
dent, was  kept  wet  with  an  evaporating  lotion  ;  the 
regular  action  of  the  bowels  was  elicited  by  occa- 
sional aperients,  and  she  generally  took  at  bed-time, 
for  an  old  chronic  cough,  an  anodyne  pill.  For  some 
weeks  I  found  that  I  could  extend  the  limb  when  I 
wished,  but  afterwards  I  could  not  accomplish  this, 
1  supposed  from  the  permanent  contraction  of  the 
muscles  of  the  pelvis;  this  I  presumed  was  more 
especially  the  case,  as  the  opposite  thigh  was  bent 
at  the  same  angle,  and  was  equally  immovable. 
As  she  was  become  perfectly  bed-ridden,  to  which 
state  of  imbecility  she  might  be  said  to  be  rapidly 
approaching  even  before  the  accident,  she  had 
sloughing  of  the  integuments  of  the  parts  upon  which 


168 


FRACTURES   OF  THE  UPPER  PART 


she  lay,  but  did  not  suffer  other  inconvenience.  Her 
general  health  appeai-ed  nearly  as  good  as  before 
the  accident;  and  she  ultimately  sunk  \vithout  any 
symptom  of  active  disease,  about  fifteen  months 
from  the  period  at  which  the  fracture  took  place. 

Inspection, 

The  limb  was  drawn  up  at  right  angles  with  the 
body,  or  nearly  so.  I  removed  the  os  innominatum 
with  the  thigh-bone,  and  presented  them  to  Sir 
Astley  Cooper,  and  the  following  is  the  account  of 
(he  dissection. 

Dissection, 

The  neck  of  the  thigh-bone  had  been  broken  at 
its  junction  with  the  body  of  the  bone,  and  had  been 
forced  into  the  cancellated  structure  between  the 
trochanter  major  and  trochanter  minor,  where  it 
had  been  united  with  the  cancelli.  But  the  most 
curious  circumstance  in  this  dissection  was,  that  in 
order  to  give  the  support  which  the  body  required 
for  a  limb  in  such  a  state,  an  addition  had  been  made 
both  to  the  trochanter  major  and  the  troclianter 
minor,  by  which  means  they  rested  against  the  edge 
of  the  acetabulum,  and  in  every  slight  change  of 
position,  would  give  an  opportunity  for  the  weight 
of  the  body  to  be  supported  by  these  processes 
resting  on  the  os  innominatum.    (See  Plate.) 

James  Powell. 


My  friend,  Mr  Roux,  sent  me  from  Paris  a  frac- 
tured thigh-bone,  in  which  the  neck  of  the  bone 
had  been  broken  at  the  same  part,  as  in  Mr  Powell's 
case,  and  had  been  united  in  a  similar  manner.  But 
it  frequently  happens  in  this  injury,  that  the  frac- 
ture of  the  neck  of  the  thigh-bone  is  complicated 


OF  THE  THIGH-BONE. 


169 


with  an  injury  of  the  trochanter  major  and  trochan- 
ter minor. 

Mr  Wray,  surgeon,  in  Fleet  Street,  was  so  kind  as 
to  present  me  with  a  fracture  of  this  description, 
and  the  folhnving  are  the  particulars  of  the  case. 

Case,  —  A  man,  aged  sixty-four,  was  standing  by 
his  bed-side,  when  he  suddenly  fell  to  the  ground, 
as  it  was  supposed  in  a  fit,  and  on  tho  attempt  to 
raise  him,  he  was  found  unable  to  stand.  Mr  \¥ray 
was  called  to  him,  and  he  found  his  right  leg  some- 
what shorter  than  the  other,  and  the  limb  everted. 
Motion  of  the  limb  gave  him  excessive  pain;  no 
crepitus  could  be  perceived  in  the  examination  which 
he  would  permit  Mr  Wray  to  make.  The  limb 
was  placed  in  a  straight  position,  and  a  constitutional 
treatment  was  pursued,  but  a  high  degree  of  irrita- 
tive fever  succeeded,  and  on  the  fourth  day  from  the 
accident  the  man  died.  Upon  the  examination  of 
the  body,  great  extravasation  of  blood  was  found 
both  externally  to  the  muscles  and  between  them; 
suppuration  had  commenced  near  the  trochanter 
major,  and  a  fracture  was  found  at  the  neck  of  the 
thigh-bone  and  into  the  trochanter,  by  which  the 
neck  had  been  received  into  the  cancellated  struc- 
ture of  the  shaft  of  the  bone. 

Mr  Travers  has  a  most  valuable  specimen  of  this 
fracture,  which  occurred  in  a  patient  of  his  at  St 
Thomas's  Hospital,  and  of  which  he  had  the  kind- 
ness to  give  me  the  following  account. 

Case. —  Richard  Norton,  aged  sixty,  fell  upon  the 
curb-stone  of  the  foot-pavement,  and  struck  the  up- 
per and  outer  part  of  his  left  thigh  with  great  vio- 
lence. He  was  admitted  into  St  Thomas's  Hospital, 
on  the  24th  of  January,  1818.  The  tension  was 
then  considerable  ;  the  line  of  the  tensor  vagin{e 
22 


170 


FRACTURES  OF  THE   UPPER  PART 


femoris  formed  an  arch  ;  the  limb  was  shortened; 
the  foot  inclined  outwards;  the  motion  of  the  limb 
was  free  in  all  directions  ;  but  it  was  painful,  more 
especially  when  the  knee  was  carried  over  the 
opposite  thigh.  The  crepitus  of  the  trochanter  major 
was  distinctly  felt  in  these  motions,  and  the  swelling 
of  the  parts,  with  the  extensive  crepitus,  gave  an 
idea  that  the  effect  of  the  accident  was  a  comminut- 
ed state  of  the  trochanter,  and  that  the  base  of  the 
cervix  femoris  was  broken  ;  hence  the  shortening  of 
the  leg,  and  the  eversion  of  the  foot.  After  the 
use  of  evaporating  lotions  for  some  days,  the  tension 
subsided,  so  as  to  allow  the  application  of  the  long 
outer  splint  and  two  thigh-splints  well  bedded.  On 
March  the  4th,  the  splints  were  removed,  and  union 
appeared  to  have  taken  place,  for  the  limb  had  re- 
sumed its  natural  figure,  but  was  a  little  shorter  than 
the  other.  In  the  course  of  a  month  more  he  began 
to  use  his  crutches.  On  April  the  15th,  he  was 
placed  under  the  physician  for  defect  in  his  general 
nealth;  and  when  he  was  upon  the  point  of  quit- 
ting the  hospital,  he  was  seized  with  spasms  in  his 
chest,  of  which  he  suddenly  expired. 

Upon  examination,  some  old  adhesions  of  the 
pleura,  and  water  in  the  chest,  and  pericardium, 
were  found.  The  fracture  was  through  the  tro- 
chanter, as  had  been  supposed,  extending  some  way- 
down  the  bone,  and  it  apparently  had  united,  with 
very  slight  deformity  ;  but  on  maceration,  the  head 
and  neck  of  the  bone  became  loose  in  the  thigh- 
bone, and  a  fracture  was  found  there,  which  locked 
the  head  and  cervix  in  a  shell  of  bone  formed 
aroimd  them.  B.  Travers. 


Mr  Travers  having  sent  me  the  bone,  the  follow- 
ing are  the  appearances  of  this  curious  case.  The 


OF  THE  THIGH-BONE. 


171 


head  and  cervix  had  been  separated  from  the  tro- 
chanter major  and  body  of  the  bone.  The  upper 
part  of  the  thigh-bone  was  obhquelj  split,  so  as  to 
receive  the  cervix  femoris  into  the  cancelli.  Tiiis 
fracture  of  the  thigh-bone  separated  the  posterior 
portion  of  the  trochanter  major  from  the  body  of 
the  thigh-bone,  and  the  trochanter  minor  was  re- 
moved with  it.  An  union  had  taken  place  between 
the  fractured  portions  of  the  trochanter,  at  a  slight 
distance  from  each  other,  and  thus  a  hollow  was  left, 
into  which  the  cervix  femoris  was  received,  and  it 
had  not  yet  become  united  by  ossific  deposit,  as  the 
man  had  not  lived  sufficiently  long  for  firm  consoli- 
dation under  his  reduced  state;  for  upon  maceration, 
the  neck  of  the  bone  had  free  play  in  the  cavity  in 
which  it  had  been  received,  and  from  which  it  could 
not  be  removed. 

Mr  Oldnow,  of  Nottingham,  who  is  a  very  intel- 
ligent surgeon,  sent  me  two  very  excellent  speci- 
mens of  this  fracture,  in  which  the  necks  of  the 
bones  were  broken  at  their  junction  with  the  tro- 
chanter major.  The  trochanter  major  itself  had 
been  also  broken  off,  and  the  trochanter  minor 
formed  a  distinct  fracture.  The  bones  had  become 
re-united;  the  cervix  femoris  to  the  shaft  of  the 
bone,  and  the  trochanter  minor  a  little  higher  than 
its  natural  attachment.  The  trochanter  major  was 
in  one  specimen  re-united  to  the  body  of  the  bone, 
but  not  in  the  other.  Thus  the  thigh-bone  was  at 
its  upper  part  divided  into  four  portions;  the  head 
and  neck  of  the  bone  formed  one  portion ;  the  tro- 
chanter major  a  second  ;  the  trochanter  minor  a 
third;  and  the  body  of  the  bone  the  fourth.  The 
union  was  accompanied  by  very  little  shortening  of 
the  thigh.    (See  Plate.) 

Since  the  publication  of  a  former  edition  of  this 
work,  I  have  inspected,  with  Mr  Key,  a  fracture  of 


172  FRACTURES  OF   THE  UPPER  PART 


the  neck  of  the  thigh-bone.  The  moment  I  had 
examined  the  patient,  I  pronounced  the  case  to  be 
a  fracture  external  to  the  capsule,  and  was  led  to 
believe  so  from  some  little  diminution  in  the  length 
of  the  limb;  from  the  ecchjmosis  which  attended 
it;  from  its  distinct  crepitus  without  any  rotation; 
from  the  diminished  motion  of  the  upper  part  of 
the  thigh  ;  from  the  sunken  state  of  the  trochanter; 
and  from  excitement  of  great  pain  by  the  smallest 
motion.  This  man  died  in  a  fortnight  after  the 
accident. 

When  the  body  was  placed  upon  the  table  for 
examination,  post  mortem,  all  the  limbs  were  rigid  * 
from  the  fixed  contraction  of  the  muscles,  and,  con- 
sequently, the  thigh  was  drawn  up  to  its  greatest 
possible  extent ;  yet  the  limb  was  found  to  be  not 
quite  three-quarters  of  an  inch  shorter  than  the 
other.  The  posterior  part  of  the  sheath  of  the 
vessels,  and  some  branches  of  blood-vessels,  were 
torn  by  the  bone,  which  accounted  for  the  ecchy- 
mosis.  The  neck  of  the  bone  was  forced  into  the 
cancelli  of  the  trochanter  major. 

Before  writing  this  statement,  I  again  inquired  of 
Mr  Key,  the  degree  of  diminution  in  the  length  of 
the  limb,  and  his  answer  was,  'If  you  mention  three- 
quarters  of  an  inch,  you  will  state  rather  more  than 
its  degree  of  retraction,  even  when  all  the  muscles 
were  contracted  to  their  utmost  rigidity.'  1  shall  be 
happy  to  show  the  parts  which  I  removed  from  the 
case,  with  all  the  surrounding  muscles,  to  any  person 
who  wishes  to  see  them,  as  they  at  once  explain  the 
nature  of  the  accident,  and  the  reason  why  the  limb 
is  so  little  shortened. 

Although,  then,  this  accident  has  some  of  the 
marks  of  fracture  of  the  neck  of  the  bone  within 
the  ligament,  yet  it  unites  by  bone,  and  it  will  be 
seen  that  the  union  is  similar  to  that  of  other  bones 


OP  THE  THIOH-BONE. 


173 


external  to  the  joints;  cartilage  is  first  deposited, 
and  then  the  matter  of  bone,  because  in  this  case 
the  parts  can  be  brought  into  apposition,  and  the 
ends  of  the  bones  are  confined  together  by  the  sur- 
rounding nnuscles;  one  portion  is  pressed  against  the 
other,  and  the  neck  of  the  bone  sinks  deeply  into 
the  cancellated  structure  of  the  trochanter;  thus  di- 
rect approximation  and  pressure  are  preserved  when 
the  fracture  is  at  the  junction  of  the  cervix  with  the 
trochanter,  and  the  nutrition  of  each  extremity  of 
the  bone  is  well  supported  by  the  vessels  which  pro- 
ceed to  it  from  the  surrounding  parts. 

Difference  of  opinion  reconciled, — We  now  see  the 
reason  of  the  difference  of  opinion  respecting  the 
union  of  fracture  of  the  neck  of  the  thigh-bone. 
In  the  internal  fracture  the  bones  are  not  applied 
to  each  other,  and  the  nutrition  of  the  head  of  the 
bone  being  imperfect,  in  general  no  ossific  change  is 
produced ;  but  in  the  external  fracture  the  bones 
are  held  together  by  the  surrounding  parts,  easily 
kept  in  apposition  by  external  pressure,  and  there  is 
not  only  ossific  union,  but  very  exuberant  callus. 
Much  time  is  required  in  these  accidents  to  produce 
a  complete  ossific  union;  and  the  neck  of  the  bone, 
received  into  the  cancelli,  moves  for  a  long  period  in 
its  new  situation;  although  it  is  so  far  locked  in  as 
to  prevent  its  separation. 

Treatment.  —  In  the  treatment  of  this  injury,  the 
principle  is,  to  keep  the  bones  in  approximation  by 
pressing  the  trochanter  towards  the  acetabulum  ; 
and  the  length  of  the  limb  is  preserved  by  applying 
a  roller  around  the  foot  of  the  injured  leg,  and  by 
binding  the  feet  and  ankles  firmly  together,  so  as  to 
prevent  their  retraction,  and  thus  cause  the  uninjur- 
ed side  to  serve  as  the  splint  to  that  which  is  frac- 
tured, giving  it  a  continued  support.      A  broad 


174 


FRACTURES  OF  THE  UPPER  PART 


leathern  strap  should  also  be  buckled  around  the 
pelvis,  including  the  trochanter  major,  to  press  the 
fractured  portions  of  the  bone  firmly  together  ;  and 
the  best  position  for  the  limb  is,  to  keep  it  in  a 
^straight  line  with  the  body. 

The  following  plan  I  have  also  known  successful: 
—  The  patient  being  placed  on  a  mattress  on  his 
back,  the  thigh  is  to  be  brought  over  a  double  in- 
clined plane  composed  of  three  boards,  one  below, 
Avhich  is  to  reach  from  the  tuberosity  of  the  ischium 
to  the  patient's  heel,  and  the  two  others  having  a 
joint  in  the  middle  by  which  the  knee  may  be  raised 
or  depressed  ;  a  few  holes  should  be  made  in  the 
board,  admitting  a  peg,  which  prevents  any  change 
in  the  elevation  of  the  limb  but  that  which  the  sur- 
geon directs;  over  these  a  pillow  must  be  thrown, 
to  place  the  patient  in  as  easy  a  position  as  possible.* 
(See  Plate,) 

Recovery, — When  the  Vimb  has  been  thus  extend- 
ed, a  long  splint  is  placed  upon  the  outer  side  of  the 
thigh  to  reach  above  the  trochanter  major,  and  to 
the  upper  part  of  this  is  fixed  a  strong  leathern 
strap,  which  buckles  around  the  pelvis,  so  as  to 
press  one  portion  of  bone  upon  the  other ;  and  the 
lower  part  of  the  splint  is  fixed  with  a  strap  around 
the  knee  to  prevent  its  position  from  being  altered; 
the  limb  must  be  kept  as  steady  as  possible  for 
many  weeks,  and  the  patient  may  be  permitted  to 
rise  from  his  bed  when  the  attempt  does  not  give 
him  much  pain;  he  is  still  to  retain  the  strap  which 
I  have  mentioned  round  the  pelvis;  and  by  this 

*  The  construction  of  this  inclined  plane  is  so  little  compli- 
cated, that  it  may  be  made  at  the  instant  of  two  common  boards, 
one  of  which  is  to  be  sawn  through  nearly  at  the  middle,  and  if 
hinges  cannot  be  immediately  procured,  the  boards  may  be  nailed 
together  thus  — "  ^""^ — — A.  C. 


OF  THE  THIGH-BONE*  175^ 

treatment  he  will  ultimately  recover,  with  a  useful, 
though  shortened  limb. 


FRACTURES  THROUGH  THE  TROCHANTER  MAJOR. 

Oblique  fractures  sometimes  happen  through  the 
trochanter  major,  and  the  cervix  ossis  femoris  does 
not  participate  in  the  injury.  This  accident  occurs 
at  every  period  of  life,  and  its  symptoms  are  as  fol- 
low:—  The  leg  is  very  little,  and  sometimes  not  at 
all,  shorter  than  the  other, and  the  foot  is  benumbed; 
in  some  cases  the  patient  is  unable  to  turn  in  bed 
without  assistance,  and  the  attempt  gives  him  great 
pain.  The  broken  portion  of  the  trochanter  major 
is,  in  soaie  cases,  drawn  forward  towards  the  ilium; 
in  others,  it  falls  towards  the  tuberosity  of  the  ischi- 
um ;  but  is,  in  general,  widely  separated  from  that 
portion  which  remains  connected  with  the  neck  of 
the  bone.  The  foot  is  greatly  everted  ;  the  patient 
cannot  sit,  and  any  attempt  to  do  so  produces  exces- 
sive pain.  Crepitus  is  with  difficulty  discovered  if 
the  trochanter  is  either  much  fallen,  or  much  drawn 
forwards. 

The  distinguishing  marks  of  this  accident  are,  a 
fixed  state  of  the  upper  part  of  the  trochanter, 
whilst  its  lower  part  obeys  the  motion  of  the  thigh- 
bone;  eversion  of  the  foot,  and  the  very  perceptible 
altered  position  of  the  trochanter  major;  attended 
with  crepitus  under  very  extended  motion  of  the 
upper  part  of  the  limb,  and  with  little  diminution  of 
its  length. 

But  when  the  fracture  happens  below  the  inser- 
tion of  the  principal  rotatory  muscles,  the  lower  por- 
tion of  bone  is  much  raised  by  the  action  of  the 
gluteus  maximus,  and  the  limb  becomes  very  much 


176  FRACTURES    OF   THE   UPPER  PART 

shortened  and  deformed  at  the  place  of  union  by 
exuberant  callus. 

This  fracture  unites  very  firmly,  and  more  quickly, 
than  when  the  cervix  is  broken  at  the  root  of  the 
trochanter,  and  the  patient  recovers  with  a  very 
good  use  of  the  limb. 

The  first  case  of  this  kind  1  ever  saw  was  in  St 
Thomas's  Hospital,  about  the  year  1786.  It  was 
supposed  to  be  a  fracture  of  the  neck  of  the  thigh- 
bone within  the  capsule,  and  the  limb  was  extended 
over  a  pillow  rolled  under  the  knee,  with  splints  on 
each  side  of  the  limb,  by  Mr  Cline's  direction.  An 
ossific  union  succeeded,  with  scarcely  any  deformity, 
excepting  that  the  foot  was  somewhat  everted,  and 
the  man  walked  extremely  well.  When  he  was  to 
be  discharged  from  the  hospital  a  fever  attacked 
him,  of  which  he  died  ;  and  upon  dissection,  the 
*fracture  was  found  through  the  trochanter  major, 
and  the  bone  was  united  with  very  little  deformity, 
so  that  his  limb  would  have  been  equally  useful  as 
before. 

The  following  case  I  attended  with  Mr  Harris, 
surgeon,  at  Reading,  who  has  been  so  kind  as  to 
communicate  the  circumstances  in  detail. 

Case.  —  On  Friday,  July  20th,  1821,  I  was  sent 

for  to  Mr  B  ,  a  gentleman,  living  about  six  miles 

from  Reading,  who,  I  understood  from  the  servant, 
had  met  with  an  accident,  and  put  out  his  hip.  I 
found  him  placed  on  a  board  in  his  bed  room,  and  on 
inquiry  learnt  that  his  horse  had  fallen  with  him 
when  putting  him  into  a  trot,  and  he  was  thrown, 
and  fell  on  his  left  hip  on  the  road.  He  immediately 
got  on  his  legs,  and  walked  a  few  steps,  but  soon 
found  an  inability  to  bring  his  left  leg  forward,  and 
con)plained  of  [)ain  in  his  left  hip.  He  was  placed 
in  a  cart,  and  supporting  his  left  leg  by  taking  the 


OF  THE  THIGH-BONE. 


177 


stirrup  and  placing  his  foot  in  ll,  holding  it  steady  by 
the  leather,  he  was  conveyed  home,  a  distance  of 
about  four  uiilcs.  1  reached  him  within  two  hours 
of  tlie  accident,  and  on  examining  the  hmb  I  imtne- 
thately  perceived  that  tl)ere  was  not  a  dislocation. 

I  could  not  discover  any  crepitus  in  rotating  the 
limb;  it  was  of  the  same  length  as  the  other,  and 
neither  turned  inwards  nor  outwards;  and  he  had 
the  power  of  retaining  it  in  any  position  in  which  you 
chose  to  place  it.  The  integuments  in  the  neigh- 
bourhood of  the  trochanter  U];ijor  wore  a  good  deal 
swollen;  and  he  complained  of  pain,  but  could  bear 
the  limb  to  be  moved  in  any  direction,  without  much, 
or  indeed  any  inconvenience,  excej)t  when  drawn 
across  the  olJier,  and  then  great  pain  was  felt  in  the 
situation  of  the  trochanter  minor.  1  then  gave  it  as 
my  opinion,  that  there  was  neither  dislocation  nor 
fracture,  and  I  thought  he  would  be  well  in  a  few 
days.  I  directed  some  leeches  to  be  applied  over 
the  trochanter  major,  and  an  evaporating  lotion,  and 
took  about  twelve  ounces  of  blood  from  the  arm; 
and  as  he  was  in  the  habit  of  taking  the  pil :  hydrarg: 
I  directed  him. to  take  a  pill  at  bed-time,  and  some 
Cheltenham  salts  in  the  morning. 

I  should  observe,  that  in  making  my  examination, 
I  discovered  that  Mr  B   had  formerly  experi- 

enced a  fracture  of  the  patella  of  the  right  knee, 
which  had  united  by  a  ligament  of  near  two  inches 
in  length  ;  and  on  inquiry  I  learnt,  that  it  had  been 
fractured  three  times  —  in  1705,  1790,  and  1800. 
He  is  of  tall  stature,  and  rather  thin  ;  and  at  the 
time  of  the  present  accident  is  in  the  fifty-first  year 
of  his  ao^e. 

On  seeing  Mr  B  the  next  day,  the  21st,  I 

found  he  had  had  no  sleep,  and  was  totally  unable  to 
move  the  limb  u^ithout  assistance  ;  his  medicine  had 
operated.    On  the  22nd  there  was  no  improvement 
23 


178  FRACTURES   OF  THE  UPPER  PART 


in  the  powers  of  the  limb;  the  part  was  still  much 
swollen,  although  the  leeches  had  drawn  a  consider- 
able quantity  oi*  blood.  As  there  was  a  disposition 
to  inflammation  from  the  bite  of  the  leeches,  I  or- 
dered a  poultice  of  linseed  meal  and  brea'd  crumbs, 
which  removed  it  in  a  day  or  two.  Mr  B  in- 
formed me,  that  Mr  Ring,  of  Reading,  had  called  on 
him,  had  examined  the  limb  very  minutely,  had 
measured  it  and  found  it  to  correspond  in  length 
with  the  other;  after  which  he  observed,  that  he  was 
happy  to  confirm  Mr  Harris's  opinion  of  the  case. 

On  the  26th,  Mr  B  was  attacked  with  an 

acute  hepatitis,  which  very  nearly  proved  fatal. 
From  that  time  to  the  28th,  he  was  bled  four  times 
from  the  arm,  to  the  extent  of  ninety-six  ounces  of 
blood,  and  took  a  saline  purgative  draught  and  cal- 
omel;  during  this  period  tlie  limb  remained  in  much 
the  same  state.  Dr  Taylor  saw  him  about  this  time. 
The  limb  was  moved  daily,  and  I  began  to  think 
that  it  did  not  improve  so  much  as  it  ought  ;  as  it 
appeared  at  first  to  be  only  a  simple  contusion,  and 
the  antiphlogistic  treatment  pursued,  for  the  cure  of 
the  hepatitis,  should  also,  we  thought,  have  benefit- 
ed the  limb. 

On  August  the  14th,  whilst  Mr  Ring  was  moving 
the  leg,  he  thought  he  felt  a  crepitus,  which  he 
communicated  to  me,  and  I  remarked  that  it  was 
impossible.  I  did  not  move  the  limb  on  that  day, 
but  on  the  following  I  rotated  it,  and  distinctly  lelt 

and  heard  the  crepitus.    Mr  B  also  heard  it, 

and  said,  '  Why,  you  do  not  mean  to  find  a  fracture 
now  !'  I  expressed  my  fears  that  there  was  a  I'rac- 
ture,  but  could  not  say  where,  but  thought  it  was 
through  the  cervix  of  the  femur;  altliough  every 
symptom,  savins^  the  crepitus,  was  wanting  to  such 
an  accident.  Having  communicated  my  opinion,  it 
was  ini mediately  arranged  for  Mr  Brodie  to  be  sent 


OF  THE  THIGH-BONE. 


179 


for,  who  came  the  followingdaj  at  noon  (the  18th),  and 
met  Dr  Taylor,  Mr  Ring,  and  niyseU".  The  partic- 
ulars of  the  case  were  communicated  to  him,  and  he 
proceeded  to  examine  the  limb,  moving  it  in  every 
direction  ;  but  could  not  then  discover  a  crepitus,  or 
anv  symptom  denoting  a  fracture,  as  the  limb  was 
still  of  the  same  length  with  the  other,  and  neither 
turned  inwards  nor  outwards.  MrBrodie  was  in  the 
first  instance  doubtful  as  to  the  existence  of  iVac- 
ture.  We  told  him  that  both  Mr  Ring  and  myself 
had  distinctly  felt  the  crepitus,  and  that  it  was  not 
discoverable  but  on  certain  motions  of  the  limb.  Mr 
Brodie  then  examined  the  limb  with  the  greatest  at- 
tention, and  in  rotating  it  very  extensively  he  felt  the 
crepitus.  Yet  when  the  patient  was  standing  up- 
right out  of  bed,  supported,  and  with  the  right  leg 
elevated  from  the  ground,  he  bore  very  considerably 
on  the  injured  limb,  so  much  so,  as  to  produce  from 
Mr  Brodie  an  exclamation  of  surprise  ;  and  he  gave 
it  as  his  opinion,  that  such  was  the  obscurity  of  the 
case,  that  had  he  seen  it  a  week  before,  he  should 
decidedly  have  said  that  there  was  not  a  fracture, 
as  in  fact  every  symptom  at  that  time  was  complete- 
ly wanting,  except  the  inability  to  move  the  limb; 
but  now  he  believed  a  fracture  existed  in  the  cervix 
femoris,  or  in  the  superior  part  of  the  thigh-bone, 
where  the  cervix  joins  it. 

The  treatment  recommended  by  Mr  Brodie  was, 
a  long  splint  placed  on  the  outside  of  the  limb,  and  a 
bandage  from  the  toes  to  the  hip,  which  he  applied 
himself,  and  he  ordered  it  to  be  worn  for  one  month, 
and  that  the  limb  should  be  kept  entirely  free  from 
motion. 

At  the  expiration  of  a  month  Sir  A.  Cooper  was 
sent  for,  who  arrived  September  the  11th.  After 
the  accident  had  been  stated  to  him,  he  proceeded 
to  examine  the  limb  ;  he  first  observed  the  relative 


180 


FRACTURES  OF  THE  UPPER  PART 


position  of  the  two  limbs  (Mr  B  still  lying 

on  his  back,  with  ,the  llinb  resting  on  the  heel), 
and  then  passing  his  hand  under  the  trochanter 
major,  he  raised  it  easily,  it  having  now  dropj)ed 
from  its  natural  position;  and  he  agreed  with  Mr 
Brodie  and  ourselves  in  declaring  the  fracture  to 
exist  in  the  trochanter  major,  where  it  unites  with 
the  cervix  femoris. 

The  treatment  recommended  by  Sir  A.  Cooper 
was,  to  keep  the  trochanter  in  its  proper  position; 
the  patient  to  remain  in  the  horizontal  posture  ;  and 
the  most  perfect  quiet  to  be  observed. 

The  means  adopted  to  accomplish  these  objects 
were  the  following. 

A  mattress  was  made  of  horse-hair  about  five 
inches  thick,  and  very  smooth,  and  this  was  cover- 
ed with  a  sheet.    A  part  of  the  mattress  was  made 
to  draw  out  on  the  side  opposite  to  the  fracture,  so 
that  when   the  necessary  evacuations  took  place, 
there  still  should  be  no  motion  of  the  body.  Be- 
fore drawing  out  the  piece  of  mattress,  a  board  of 
two  feet  long,  and  six  inches  wide,  shaped  like  a 
wedge,  was   insinuated  under  the  buttock  of  the 
right  side,  the  two  ends  of  the  board  resting  on  the 
mattress;  thereby  preventing  the  nates  from  sink- 
ing at  all  into  the  oj)cning  when  the  piece  of  mat- 
tress was  removed,  and  the  injured  side  still  rested 
on  the  body  of  the  mattress:  the  board  was  of 
course  removed  after  the  mattress  was  replaced. 
Upon  the  bedstead  w'as  first  placed  a  thick  smooth 
board,  sufficiently  large  to  cover  the  bottom  of  the 
bed,  and  on  that  was  placed  the  mattress,  thereby 
preventing  any  sinking  from  pressure  of  the  body. 

The  bandage  recommended  by  Sir  A.  C.  was  the 
following:  —  a  broad  web,  sufficient  to  go  round  the 
body  over  the  hips,  was  fixed  with  two  buckles  and 
straps,  and  a  piece  was  added  to  make  it  wider 


OF  THE  THIGH-BONE. 


181 


where  it  passed  under  the  injured  troehanter;  this 
was  lined  with  chamois  leather,  and  stuffed  :  a  pa  1 
of  the  same  leather,  about  six  inches  loni^,  three 
broad,  and  three  inches  thick,  and  ending  gradually 
in  a  point,  was  placed  immediately  under  the  tro- 
chanter major  of  the  injured  side,  so  that  when  the 
bandage  was  buckled,  the  pad  passed  into  the  hol- 
low beneath  the  trochanter,  and  when  the  bandage 
was  tightened,  it  forced  the  troclianter  upwards  and 
forwards  into  its  natural  position  :  another  pad  made 
very  thick,  about  eight  inches  square,  in  the  shaj)e 
of  a  w^edge,  was  placed  under  the  upper  part  of  the 
thigh,  after  the  bandage  was  attached.  The  patient 
was  placed  on  his  back,  the  limb  resiing  on  the 
heel  ;  and  to  prevent  the  possibility  of  any  motion 
of  the  foot  and  of  the  body, a  wide  board  was  fixed 
to  the  bed-posts  at  the  foot  of  the  bed,  with  two 
pieces  of  wood  padded  and  fastened  to  it,  into  which 
the  foot  was  received,  and  the  least  lateral  motion 
prevented.  A  cushion  was  placed  opposite  to  the 
other  foot,  so  that  pressure  could  be  made  against 
the  board,  and  the  body  was  thus  prevented  from 
slipping  down  in  the  bed. 

Sir  A.  C.  gave  directions  that  Mr  B  should 

not  quit  the  horizontal  posture;  and  ordered  him 
occasional  purges,  and  a  generous  diet.  T'  is  treat- 
ment was  adopted  September  the  13th;  lie  passed 
a  tolerable  night,  and  did  not  complain  of  the  band- 
age. Nothing  particular  occurred  during  the  month, 
except  that  the  patient  suffered  occasionally  from 
bilious  head-ache  and  vomiting,  which  were  remov- 
ed by  purging.  The  bandage  was  tightened  every 
now  and  then,  but  not  to  any  great  degree  till  the 
expiration  of  three  weeks,  when  he  expressed  him- 
self certain  that  he  still  felt  the  crepitus;  upon 
which  I  urged  the  absolute  necessity  there  was  for 
tightening  the  bandage,  and  thus  by  pressure  pro- 
duce a  degree  of  inflammatory  action  in  the  bone. 


182 


FRACTURES  OF  THE  UPPER  PART 


I  should  j^dge  that  when  Sir  A.  C.  saw  Mr 

B  ,  iUe  ends  of  the  bone  were  as  much  as 

two  inches  apart^  but  that  was  most  certainly  not 
the  case  when  Mr  Brodie  examined  the  limb;  the 
separation  had  taken  place  during  the  month. 

From  this  time  the  bandage  was  kept  as  tight  as 
it  could  possibly  be  borne  (and  it  never  shifted  in 
the  least  from  the  position  in  which  it  was  first 
placed),  and  no  feeling  of  crepitus  was  afterwards 
complained  of.  The  swellirig  of  the  thigh  and  leg 
was  much  increased,  as  if  distended  with  coagulable 
lymph  ;  it  pitted  on  pressure,  but  some  degree  of 
force  was  requisite  to  produce  that  effect.  Pain 
was  still  complained  of  in  the  direction  of  the  tro- 
chanter minor  ;  the  bowels  were  torpid,  and  requir- 
ed opening  medicine  every  other  day. 

Sir  A.  C.  visited  Mr  B  a  second  time, 

October  .  JGth  ;  the  bandage  was  not  removed,  nor 
was  the  position  changed.  He  gave  it  as  his  opinion 
that  union  had  begun,  and  directed  the  patient  to 
continue  in  the  same  position,  which  he  did,  without 
any  thing  material  occurring  except  bilious  attacks, 
till  December  the  30th,  when  Sir  A.  C.  visited  him 
a  fourth  time  :  he  had  seen  him  in  the  interval  be- 
tween October  the  IGth  and  December  the  30th, 
but  nothing  particular  had  occurred. 

On  December  the  30th,  Sir  A.  C.  removed  the 
bandages  for  two  hours;  the  bone  remained  in  its 
natural  position;  and  on  examination  we  could  feel 
a  great  thickening  of  the  [)arts  about  the  trochan- 
ter.* He  ordered  him  to  stand  at  the  side  of  the 
bed  after  the  bandage  had  been  removed,  and  he 
stood  with  support  a  few  minutes,  when  he  became 
faint,  and  was  removed  to  his  bed.  Sir  A.  C.  wish- 
ed the  bandage  to  be  re-applied  once  a  day  for  an 
hour,  and  the  limb  to  be  rubbed  from  the  foot  up- 


OF  THE  THIGH-BONE. 


183 


wards.  The  thiii;h  became  much  softer  during  the 
two  hours  in  which  ihe  bniidagc  was  retnoved  ;  the 
boards  whicli  supported  the  foot  were  now  also  re- 
moved, as  well  as  tlie  bandages,  and  Mr  B  

was  placed  on  crutches.  From  this  time  he  rose 
every  day;  and  the  hrab  continuing  very  much 
swollen,  it  was  rubbed  daily  from  two  to  four  hours  ; 
still  he  could  not  bend  the  knee  ;  but  when  standing 
on  liis  crutches  he  had  a  most  perfect  use  of  the 
hip-juint.  We  endeavoured  to  regain  the  motion  of 
the  knee  by  friction  with  oily  embrocations.  On 

Friday,  March  1st,  Mr  B  -—  left  E  in 

his  carriage  for  London.  Samuel  Harris. 

Since  his  arrival  in  London,  Mr  B  —  has, 

with  great  steadiness,  employed  friction  and  passive 
motion  for  the  recovery  of  the  use  of  the  knee  with 
the  happiest  effect,  and  the  hip-joint  is  entirely  re- 
stored to  its  natural  powers.  A.  C. 

Case,  —  Mr  Peggler,  of  Wanstead,  aged*forty-six, 
on  the  13th  of  November,  UUT,  fell,  while  walking, 
on  a  glass  bottle  which  he  had  in  his  pocket;  and 
when  he  attempted  to  raise  himself  from  the  ground 
he  found  lie  was  not  able  to  stand.  In  a  quarter 
of  an  hour  he  felt  great  pain,  and  could  not  bear 
the  slightest  weight  of  his  body  on  the  injured  limb.  . 
Mr  Constable,  of  Woodford,  was  sent  for,  and  he 
gave  me  the  following  account  of  the  case.  The 
foot,  at  first,  did  not  appear  to  turn  out;  but  when 
the  patient  was  put  into  bed,  and  laid  on  his  back, 
it  became  everted  ;  the  leg  appeared  somewhat 
shorter,  but  was  with  little  difficully  pulled  down  to 
its  natural  length  ;  the  foot  was  benumbed,  and, con- 
tinued so  for  twelve  months.    He  was  placed  in  bed, 


184  FRACTURES  OF  THE  UPPER  PART 


with  a  bolster  under  the  liip  to  prevent  displace- 
ment of  the  bone;  and  his  knees  and  ankles  were 
tied  together. 

In  December  following,  about  Christmas,  I  met 
Mr  Constable,  wliilst  visiting  a  patient  with  a  severe 
injury  of  the  head,  and  he  then  requested  me  to  see 
Mr  Peggler,  wiiom  I  found  ificapable  of  turning  in 
his  bed  without  assistance,  and  the  attempt  gave  him 
great  pain;  his  injured  leg  was  a  little  shorter  than 
the  other;  the  trochanter  was  drawn  forward  to- 
wards the  spine  of  the  ilium,  and  could  be  felt  con- 
siderably separated  from  tl^at  portion  of  the  tro- 
chanter connected  with  the  neck  of  the  bone;  the 
foot  was  turned  outwards  ;  he  could  not  sit,  and  the 
least  attempt  to  raise  himself  produced  excruciating 
sufferino^.  I  broug^ht  him  to  the  foot  of  the  bed  in 
an  horizontal  position,  to  make  as  accurate  an  ex- 
amination as  I  could  of  the  nature  of  tho  accident, 
and  had  no  hesitation  in  pronouncing  it  a  fracture 
through  the  trochanter.  In  less  than  a  month  he 
began  to  use  his  crutches,  and  continued  their  use 
for  three  months  ;  he  then  laid  aside  one  crutch,  and 
employed  a  stick  and  crutch,  and  in  a  short  time 
needed  the  support  of  a  stick  only  ;  but  it  was 
twelve  months  before  he  recovered  the  entire  use 
of  his  limb.  The  leg  is  still  nearly  an  inch  shorter  than 
the  other;  the  portion  of  .the  trochanter  connected 
with  the  thigh-bone  has  united  with  the  foi'e  part  of 
the  trochanter  joined  to  the  neck  of  the  bone,  and 
is,  consequently,  much  nearer  the  spine  of  the  ilium 
than  usual  ;  the  foot  Is  also  slightly  everted,  but  he 
walks  extremely  well  ;  a  week  ago,  he  walked  ten 
miles  from  home,  and  retin-ned  the  same  day;  and 
this  day,  July  2inh,  1}U9,  he  has  walked  from  Wan- 
stead  to  my  house,  and  intends  to  walk  back,  a  dis- 
tance of  near  twenty  miles. 

This  history  of  Mr  Peggler's  accident  is  so  similar 


OF   THE  THIGH-BONE* 


to  the  cases  of  fracture  through  the  trochanter 
major  which  I  have  had  an  opportunity  of  seeing, 
that  a  detail  of  the  latter  would  be  superfluous  ;  the 
only  variations  that  I  have  witnessed  having  been 
in  the  distinctness  of  the  crepitus  accompanying 
them,  which  is  less  in  proportion  as  the  fracture  ap- 
proaches the  capsular  ligament.  I  have  lately  frac- 
tured through  the  trochanter  major,  five  diflerent 
thigh-bones  in  the  living  animal;  they  united,  but 
with  great  distension,  shortening,  and  exuberant 
callus. 

In  conclusion,  I  have  to  observe,  that  as  the  dimi- 
nution of  the  length  of  the  limb,  and  its  eversion  of 
the  knee  and  foot,  are  signs  common  to  fractures  of 
the  thigh-bone  generally,  it  may  be  proper  to  bring 
into  one  view  the  means  of  distinguishing  the  three 
species  of  fracture  which  I  have  described. 

The  fracture  of  the  cervix  within  the  capsule  is  known, 
with  very  rare  exceptions,  by  the  very  advanced  age 
of  the  patient, —  by  its  greater  frequency  in  female 
than  in  male  subjects,  —  by  the  absence  of  swelling 
and  ecchymosis, — by  the  elevation  and  advance  of 
the  trochanter, —  by  the  greater  mobility  of  the 
joint,  allowing  flexion  and  extension,  although  with 
some  pain,  and  resistance  from  muscles, — by  a  crepi- 
tus perceptible  only  on  drawing  down  the  limb  to  the 
same  length  with  the  other,  and  then  rotating  it, — 
by  the  pain  felt  at  the  trochanter  minor, —  by  the 
small  degree  of  constitutional  irritation  attending  the 
accident,  —  by  the  slight  causes  which  produce  it, 
—  and  by  the  little  local  swelling  or  change  of  ap- 
pearance which  ensues. 

Fractures  of  the  cervix  into  the  cancelli  of  the  trochan- 
ter are  known  by  the  effusion  of  blood  amidst  the 
muscles, —  by  great  swelling  produced,  and  by  ecchy- 
mosis, which  appears  soon  after  the  accident, —  by 
an  unnaturally  fixed  state  of  the  joint,  so  that  flexion 
24 


186 


FRACTURES  OF  THE  UPPER  PART 


and  extension  cannot  be  performed, —  by  excessive 
pain  on  the  least  motion  of  the  hip-joint,  and  upper 
part  of  the  thigh-bone, —  by  a  crepitus  attending  the 
least  motion  of  the  thigh-bone  without  drawing  it 
down  to  the  length  of  the  other, —  and  by  the  in- 
flammation, swelling,  and  constitutional  irritation  pro- 
duced, wliich  are  frequently  fatal. 

The  fracture  of  the  trochanter  major  may  be  easily 
known  by  the  separation  of  the  bone  at  the  part,  so 
that  the  finger  may  be  placed  between  the  fractured 
portions, —  by  the  distinct  crepitus  felt  in  putting  the 
fingers  on  the  trochanter  when  the  knee  is  advanced, 
—  by  inability  of  the  upper  portion  of  the  trochanter 
to  obey  the  motions  of  the  lower,  and  of  the  shaft 
of  the  bone, —  and  when  at  the  lower  part  of  the 
trochanter,  by  great  overlapping,  distension,  and 
exuberant  callus. 

I  have  thus  stated  what  dissection  and  observation 
have  taught  me  of  the  three  fractures  of  the  upper 
part  of  the  thigh-bone,  and  shown  it  to  be  a  general 
principle,  that  fractures  within  the  capsule  do  not 
unite  by  bone.  I  ought  to  add,  that,  in  the  Museum 
of  Mr  Langstaff,  there  is  a  preparation  of  fracture 
within,  and  of  one  external  to  the  ligament;  the  lat- 
ter firmly  united  by  bone,  whilst  the  former  has 
scarcely  undergone  any  ossific  change.  I  can  have  no 
wish  but  that  these  fractures  within  the  capsule 
should  unite  by  bone,  if  that  result  be  desirable.  I 
only  state  what  dissection  has  taught  me  ;  and  with 
respect  to  contrivances  to  produce  their  union,  I 
caiinot  extol  them  until  there  be  some  evidence  of 
their  value. 


OP  THE  THIGH-BONE. 


187 


FRACTURE    OF    THE    EPIPHYSIS    OF    THE  TROCHANTER 
MAJOR. 

Mr  Key,  Surgeon  to  Guy's  Hospital,  had  the  kind- 
ness to  send  rne  the  followino^  account  of  a  peculiar 
fracture  of  the  trochanter  major,  in  which  this  pro- 
cess was  broken  from  the  thigh-bone  at  the  part  at 
which  it  is  naturally  united  by  cartilage  as  an  epi- 
physis in  youth. 

Case.  —  The  subject  of  the  accident  was  a  young 
girl  about  the  age  of  sixteen,  who,  in  crossing  the 
street  with  a  can  in  her  hand,  tripped,  and  in  falling, 
struck  her  trochanter  violently  against  the  curb- 
stone. She  immediately  rose,  and  without  much 
pain  or  difficulty  walked  home.  The  accident  oc- 
curred on  Saturday,  March  ir)th,  1822;  and,  in  con- 
sequence of  the  increase  of  pain  she  experienced  on 
the  inner  side  of  the  thigh,  she  presented  herself  at 
Guy's  for  admission  on  the  Thursday  following.  Her 
constitutional  symptoms  beirig  evidently  more  violent 
than  those  which  usually  arise  from  fractured  femur, 
she  was  placed  under  the  care  of  the  physician,  Dr 
Bright,  at  whose  request  I  examined  the  limb.  Her 
right  leg,  which  was  the  one  iiijured,  was  consider- 
ably everted,  and  appeared  to  be  about  half  an  inch 
longer  than  the  sound  limb.  It  admitted  of  passive 
motion  in  all  directions,  but  in  abduction  gave  her 
considerable  pain.  She  had  perfect  command  over 
all  the  muscles  except  the  rotators  inwards.  The 
fact  that  she  had  walked  both  before  and  since  her 
admission  into  the  hospital,  gave  rise  to  some  doubts 
as  to  the  existence  of  a  fracture,  and  the  closest  ex- 
amination of  the  trochanter  and  body  of  the  lemur 
could  not  detect  the  slightest  crepitus  or  displace- 
ment of  bone.    I  repeated  the  examination  of  the 


188 


FRACTURES  OP  THE  UPPER  PART 


limb  on  the  following  day,  but  the  result  was  equally 
unsatisfactory. 

The  fever  under  which  she  was  labouring,  together 
with  general  abdominal  uneasiness,  threatening  her 
life,  the  limb  underwent  no  further  examination. 
She  died  on  Monday,  nine  days  after  the  accident. 

Examination  after  Death,* 

Wishing  to  ascertain  (for  I  suspected  some  ob- 
scure fracture  of  the  os  femoris)  the  exact  nature  of 
the  injury,  previously  to  removing  the  soft  parts  I 
moved  the  limb  in  every  direction,  fixing  the  tro- 
chanter and  head  of  the  bone  ;  but  I  could  perceive 
no  deviation  from  the  usual  state  of  parts,  nor  could 
I  distinguish  ■  the  slightest  crepitus  under  all  the  va- 
riety  of  movements.  1  should  observe,  that  there 
was  no  tumefaction  of  the  thigh,  and  therefore  the 
trochanter  and  head  of  the  os  femoris  were  as 
readily  distinguished  and  exposed  to  examination  as 
in  the  most  healthy  limb. 

The  capsule  of  the  joint  being  laid  bare,  a  cavity 
was  discovered  by  the  side  of  the  pectinaeus,  leading 
backwards  and  dow^nwards,  towards  the  troch^ter 
minor,  and  containing  some  pus  :  it  allowed  the 
fingers  to  pass  behind  the  bone  to  the  greater  tro- 
chanter. The  head  of  the  bone  was  then  dislocated 
by  cutting  through  the  ligaments,  and  not  till  then 
was  a  fracture  discovered  at  the  root  of  the  tro^ 
chanter  major.    The  upper  half  of  the  femur  being 

*  We  are  very  glad  to  see  so  great  a  surgeon  as  Astley 
Cooper  continue  to  use  the  English  language  as  far  as  possible, 
instead  of  adopting  the  modern  fashion  of  writing  '  jargon.' 
It  is  now  customary  to  talk  of  '  post  mortem  appearances'^  and 
'  POST  mortem  examinations^^  as  if  there  were  something  improper 
or  obscene,  in  the  words  'dissection'  or  '  Examination  after 
death.'  J.  D.  G. 


OF  THE  THIGH-BONE. 


189 


removed  from  the  body,  I  discovered  the  reason  why 
the  fracture  had  eluded  our  search. 

The  fracture  had  detached  the  trochanter  from 
the  body  and  neck  of  the  bone,  but  without  tearing 
through  the  tendons  attached  to  the  outer  side  of 
the  process.  The  tendons  are  those  of  the  two 
smaller  glutasi,  and  the  commencement  of  that  of  the 
vastus  externus ;  had  they  been  torn,  the  broken 
portion  of  bone  would  have  been  drawn  upwards  by 
the  action  of  the  two  former  muscles,  and,  in  that 
case,  the  injury  would  readily  have  been  recognised  ; 
but  they  so  effectually  prevented  all. movement  of 
the  fractured  portion,  that,  when  dissected  from  the 
bodj',  not  the  least  motion  could  be  produced  except 
in  one  direction.  It  was  found  that  this  motion  re- 
sembled that  which  would  be  produced  by  a  hinge  ; 
the  tendons  acting  the  part  of  a  broad  hinge,  and  al- 
lowing the  portion  to  be  moved  only  upwards  and 
downwards.  It  is  evident  that  such  motion  could 
not  have  been  produced  by  any  direction  given  to 
the  limb;  hence  it  is  also  manifest,  that  the  fracture 
could  not  have  been  detected  during  the  life  of  the 
patient. 


FRACTURES  BELOW   THE  TROCHANTER. 

The  thigh-bone  is  sometimes  broken  just  below 
the  trochanter  major  and  minor ;  it  is  a  difficult 
accident  to  manage,  and  miserable  distortion  is  the 
consequence  if  it  be  ill-treated.  The  end  of  the 
broken  bone  is  drawn  forwards  and  upwards,  so  as 
to  form  nearly  a  right  angle  with  the  body,  and  the 
cause  of  this  position  is  evidently  the  contraction  of 
the  iliacus  internus  and  psoas  muscles,  assisted  by 
the  pectinalis,  and  perhaps  by  the  first  head  of  the 


190       FRACTURES  OF  UPPER  PART  OF  THIGH-BONE. 


triceps.  A  better  idea  of  the  effect  of  this  accident 
may  be  obtained  by  a  view  of  the  plate,  in  which 
the  bone  will  be  observed  to  be  united,  not  only  with 
extreme  shortening,  but  with  a  hideous  projection 
forwards.  If  pressure  be  made  upon  the  projecting 
bone  in  the  treatment  of  this  case,  it  only  adds  to 
the  patient's  suffering,  and  to  the  degree  of  irritation 
of  the  limb,  without  preserving  the  bone  in  its  pro- 
per situation.  It  will  be  seen  that  this  union  exceed- 
ingly overlaps,  and  that  it  is  very  feeble;  showing, 
what  I  have  already  mentioned,  that  a  fracture  thus 
circumstanced. has  the  ossific  deposition  only  on  that 
side  where  the  inflammation  was  preserved  by  the 
pressure  of  one  bone  on  the  other.  This  prepara- 
tion may  be  seen  in  the  Anatomical  Museum,  St 
Thomas's  Hospital.    (^Sce  Plate.) 

To  prevent  this  horrid  distortion  and  imperfect 
union,  two  circumstances  are  to  be  strictly  observed: 
the  one  is,  to  elevate  the  knee  very  much  over  the 
double  inclined  plane;  and,  the  other,  to  place  the 
patient  in  a  sitting  position,  supporting  him  by  pil- 
lows during  the  process  of  union.  The  degree  of 
elevation  of  the  body  which  is  required  will  be  about 
forty-five  degrees,  but  it  may  be  readily  ascertained 
by  observing  the  approximation  of  the  fractured  ex- 
tremities of  the  bones  ;  and  this  position  is  requisite 
for  relaxing  the  psoas  and  iliacus  muscles,  and  thus 
preventing  the  elevation  of  the  upper  part  of  the 
bone.  In  no  other  manner  can  the  great  deformity 
I  have  described  be  prevented.  When,  by  this  pos- 
ture, the  extremities  of  the  bones  are  brought  into 
proper  apposition,  and  all  projection  of  its  upper  por- 
tion is  removed,  either  the  splints  may  be  applied 
which  are  commonly  used  in  fracture  of  the  thighs 
bone,  or,  what  is  better,  a  strong  leathern  belt,  lined 
with  some  soft  material,  should,  by  means  of  several 
straps,  be  buckled  around  the  limb,  and  be  confined 
by  means  of  a  strap  around  the  pelvis, 


DISLOCATIONS   OF    THE  KNEE. 


The  broad  surfaces  of  bone  by  which  the  os  fe- 
tnoris  rests  upon  the  tibia  are  calculated  to  prevent 
the  ready  dislocation  of  this  joint,  which  would  be 
otherwise  very  liable  to  happen  from  the  superficial 
nature  of  the  articulating  cavities  on  the  head  of  the 
tibia,  and  also  from  the  great  violence  to  which  the 
knee  is  frequently  exposed. 

Structure  of  the  knee;  hone,  —  The  depressions 
upon  the  head  of  the  tibia  are  increased  by  the 
addition  of  the  semilunar  cartilages  which  rest  upon 
the  bone  ;  they  receive  the  condyles  of  the  os  fe- 
moris,  and  are  attached  by  ligaments  to  the  edge  of 
the  tibia.  The  fore  part  of  the  joint  is  defended  by 
the  patella,  which  has  two  unequal  articular  surfaces 
to  play  upon  the  condyles  of  the  os  femoris.  The 
head  of  the  fibula  forms  no  part  of  the  knee-joint, 
but  is  attached  to  the  tibia  from  one  half  to  three- 
fourths  of  an  inch  below  its  head. 

Ligaments,  —  The  junction  of  the  os  femoris,  tibia, 
and  patella,  is  produced  by  means  of  a  capsular  liga- 
ment, which  proceeds  from  the  os  femoris  to  the 
head  of  the  tibia,  and  is  attached  to  the  edge  of  the 
patella,  where  it  divides  into  two  portions,  forms 


192 


DISLOCATIONS  OF  THE  KNEE. 


wings  to  that  bone,  and  takes  the  name  of  the  alaf 
ligament.  On  its  outer  side  the  capsular  ligament  is 
covered^  and  greatly  strengthened,  by  tendinous  ex- 
pansions, which  are  derived  from  the  vasti  muscles, 
and  which  proceed  to  the  head  of  the  tibia.  In- 
ternally the  ligament  has  a  secreting  synovial  sur- 
face, which  is  folded  within  the  cavities  at  the  ex- 
tremities of  the  bones,  is  reflected  to  the  edge  of  the 
articular  cartilages,  and,  it  is  believed,  forms  a  cover-, 
ing  to  those  cartilages.  Beside  the  capsular,  there 
are  several  peculiar  ligaments.  First:  The  liga- 
mentum  patellae,  which  are  extended  from  the  lower 
point  of  the  patella  to  the  tubercle  of  the  tibia.  Se- 
condly :  The  external  lateral  or  femoro-fibular  liga- 
ment, which  passes  from  the  os  femoris  to  the  head 
of  the  fibula,  and  which  divides  into  two  external 
lateral  ligaments.  Thirdly  :  The  internal  lateral  or 
femoro-tibial  ligament,  attached  to  the  os  femoris 
and  to  the  head  of  the  tibia.  Fourthly  :  The  ob- 
lique or  popliteal  ligament,  which  proceeds  from  the 
external  condyle  of  the  os  femoris  obliquely,  to  be 
inserted  into  the  head  of  the  tibia.  Fifthly  :  The 
crucial  ligaments^  which  pass  from  the  depression 
between  the  condyles  of  the  os  femoris  behind  ;  the 
one  to  a  projection  between  the  articular  surfaces 
of  the  head  of  the  tibia,  and  the  other  to  a  depres- 
sion behind  that  projection,  so  that  these  lig^aments 
cross  each  other  from  before  backwards.  The  pa- 
tella has  a  muscular  connexion  with  the  os  femoris 
by  the  insertion  of  the  rectus,  vasti,  and  cruralis. 
By  the  ligamentum  patellae  it  is  united  with  the 
tibia,  and  laterally  it  is  joined  to  the  capsular  and 
alar  ligaments.  This  ligamentous  junction  of  the 
three  bones  is  very  firm,  but  it  allows  of  free  flexion 
and  extension,  with  some  degree  of  rotatory  motion 
when  the  knee  is  bent ;  but  although  great  strength 
is  evident  in  the  construction  of  this  joint,  still  exces- 


DISLOCATIONS  Of  THE  KNEE. 


sive  violence  and  extreme  relaxation  will  occasionallj 
produce  its  dislocation. 


DISLOCATION  OF  THE  PATELLA. 

Three  directions ;  symptoms^  Src  —  The  patella 
is  liable  to  be  dislocated  in  three  directions,  namely : 
outwards,  inwards,  and  upwards.  In  its  lateral  dis- 
location, the  bone  is  most  frequently  thrown  on  the 
external  condyle  of  the  os  femoris,  where  it  produc- 
es a  great  projection  ;  and  this  circumstance,  with 
an  incapacity  of  bending  the  knee,  is  the  strong  evi- 
dence of  the  nature  of  the  injury.  The  most  fre- 
quent cause  of  the  accident  is,  that  a  person  in 
walking  or  running,  falls  with  his  knee  turned  in- 
wards, and  the  foot  outwards  ;  and  thus,  by  the 
action  of  the  muscles  to  prevent  the  fall,  the  patella 
is  drawn  over  the  external  condyle  of  the  os  femoris  ; 
and  when  the  person  attempts  to  rise  he  finds  him- 
self unable  to  bend  his  leg,  and  the  muscles  and 
ligaments  of  the  patella  are  all  forcibly  on  the 
stretch.  This  accident  generally  occurs  in  those 
who  have  some  inclination  of  the  knee  inwards, 
which,  under  the  action  of  the  extensor  muscles, 
gives  a  direction  to  the  patella  outwards. 

Internal. —  The  internal  dislocation  is  much  less 
frequent,  and  it  happens  from  falls  upon  a  project- 
ing body,  by  which  the  patella  is  struck  upon  its 
outer  side,  or  by  the  foot  being,  at  the  time  of  the 
fall,  turned  inwards.  In  cither  of  these  cases  the 
ligament  will  be  torn,  unless  there  be  some  previous 
disease. 

Mr  Harris,  getting  into  a  chaise,  caught  his  foot 
in  the  carpet  at  the  bottom  of  it,  by  which  acci- 
dent the  knee  was  turned  in  and  the  leg  outwards  ; 
25 


194  DISLOCATIONS  OF  THE  KNEE. 

the  patella  slipped  upon  the  external  condyle  of  the 
OS  femoris,  but  it  returned  very  soon,  by  the  effort 
of  the  muscles,  into  its  natural  situation.  On  ex- 
amination, I  found  the  internal  portion  of  the  capsu- 
lar ligament  torn,  and  a  great  accumulation  of  sy- 
novia in  the  joint. 

Mode  of  reduction, — The  mode  of  reduction  in 
either  case  consists  in  pursuing  the  following  plan : 
—  The  patient  is  placed  in  the  recumbent  posture, 
and  an  assistant  raises  the  leg  by  lifting  it  at  the 
heel;  the  advantage  of  which  is,  that  it  relaxes  the 
extensor  muscles  on  the  thigh  in  the  greatest  possi- 
ble degree  ;  the  surgeon  then  presses  down  that 
edge  of  the  patella  which  is  most  remote  from  the 
joint,  be  it  one  luxation  or  the  other  ;  and  this  press- 
ure raises  the  inner  edge  of  the  bone  over  the  con- 
dyle of  the  OS  femoris,  and  it  is  immediately  drawn, 
by  the  action  of  the  muscles,  into  its  natural 
situation. 

My  friend,  Mr  George  Young,  informed  me,  that 
he  was  called  to  a  case  of  dislocation  of  the  patella 
outwards,  in  which  the  reduction  was  very  difficult. 
The  patient  was  a  female,  who,  by  a  fall  in  walk- 
ing, had  the  patella  drawn  over  the  external 
condyle  of  the  os  femoris,  where  it  remained.  He 
employed  pressure  upon  the  edge  of  the  patella, 
most  perseveringly,  without  being  able  to  succeed, 
but  at  last  reduced  it  in  the  following  manner:  — 
He  placed  the  patient's  ankle  upon  his  shoulder, 
and  thus  most  completely  extended  the  limb  and 
obtained  a  fixed  point  of  resistance  at  the  knee  ; 
then  grasping  the  patella  with  the  fingers  of  his 
right  hand,  he  pressed  the  outer  edge  of  the  pa- 
tella with  the  ball  of  his  left  thumb,  and  pushed 
it  into  its  place. 

When  the  reduction  of  this  bone  has  been  effect- 
ed, an  evaporating  lotion  of  spirits  of  wine  and  wa- 


DISLOCATIONS   OF  THE  KNEE. 


195 


ter  is  to  be  applied  ;  in  two  or  three  days  the  limb 
may  be  bandaged,  and  it  is  soon  restored  to  its  na- 
tural uses,  although  it  is  somewhat  weaker  than 
before- 

I  was  informed  by  Mr  Welling,  formerly  surgeon 
at  Hastings,  that  he  was  called  to  a  case  in  which 
the  patella  was  dislocated  upon  its  edge.  The  na- 
ture of  the  accident  was  very  obvious,  as  the  edge 
of  the  bone  forced  up  the  integuments  to  a  consider- 
able height  between  the  condyles  on  the  fore  part 
of  the  joint.  Mr  Welling  reduced  the  dislocation, 
but  with  considerable  difficulty,  by  pressing  the  edges 
of  the  bone  in  opposite  directions. 

Dislocation  from  relaxation,  —  When  the  bone  is 
dislocated  from  relaxation,  the  patella  is  drawn  upon 
the  external  condyle  of  the  os  femoris  by  veny  slight 
accidents,  or  sudden  action  of  the  muscles.  My 
neighbour,  Mr  Hutchinson,  a  very  intelligent  surgeon, 
informs  me  he  has  very  frequently  seen  this  accident, 
and  that  the  tendency  to  it  has  arisen,  in  a  large  pro- 
portion of  cases,  from  the  relaxation  produced  by  ex- 
cessive indulgence  in  onanism. 

The  reduction,  in  these  cases,  is  effected  in  the 
manner  which  has  been  before  described  ;  and  after 
the  reduction,  to  prevent  any  recurrence  of  the  ac- 
cident, and  to  support  the  weakened  ligament,  a 
laced  knee-cap,  with  a  strap  and  buckle  above  and 
below  the  patella,  is  to  be  worn. 

1  once  saw  the  patella  drawn  over  the  external 
condyle  of  the  os  femoris  from  loss  of  action  of  the 
vastus  internus,  owing  to  a  disease  in  the  thigh- 
bone. 


196 


DISLOCATIONS   OF  THE  KNEE. 


DISLOCATION  OF  THE  PATELLA  UPWARDS. 

Upwards;  ligament  lacerated,  8rc,  —  In  tliis  dislo- 
cation, the  ligament  of  the  patella  is  torn  through  by 
the  action  of  the  rectus  femoris  muscle,  and  the  im- 
mediate effect  of  the  injury  is,  to  draw  the  patella 
upwards  upon  the  fore  part  of  the  thigh-bone.  The 
appearances  which  this  accident  presents  are  very 
decisive  of  its  nature  ;  for  in  addition  to  the  eleva- 
tion of  the  patella,  and  its  easy  motion  from  side  to 
side,  a  deep  depression  is  felt  above  the  tubercle  of 
the  tibia  from  the  absence  of  the  ligament;  the  pa- 
tient immediately  loses  the  power  of  bearing  upon 
that  limb,  as  the  knee  bends  under  each  attempt,  and 
he  would  fall  if  he  persisted  in  throwing  the  weight 
of  Iiis  body  upon  it.  A  considerable  degree  of  in- 
flammation is  the  consequence. 

Treatment.  —  In  the  treatment  of  this  injury,  local 
depletion  and  evaporating  lotions  are  to  be  used  dur- 
ing four  or  seven  days  from  its  occui'rence,  and  then 
a  roller  is  to  be  applied  around  the  foot  and  upon  the 
leg,  to  prevent  its  swelling  ;  the  leg  is  to  be  kept  ex- 
tended by  a  splint  behind  the  knee,  and  a  bandage, 
composed  of  a  leathern  strap,  is  to  be  buckled  around 
the  lower  part  of  the  thigh;  to  this  is  to  be  attached 
another,  which  is  to  be  carried  on  each  side  of  the 
leg,  and  under  the  foot,  and  is  to  be  buckled  to  the 
circular  strap;  thus  the  bone  is  gradually  drawn 
down,  so  as  to  allow  of  an  union  of  the  ligament.  In 
a  month  the  knee  may  be  slightly  bent,  and  as  much 
passive  motion  daily  given  as  the  patient  is  able  to 
bear;  by  these  means  the  ruptured  ligament  becomes 
united,  and  the  patella  retains  its  motion.  During  the 
time  the  bandage  is  worn,  the  patient  is  to  preserve 
(he  sitting  posture,  in  order  to  relax  the  rectus  must 


DISLOCATIONS  OF  THE  KNEE.  197 

cle  and  to  prevent  its  action  upon  the  patella.  With 
very  great  attention  the  union  becomes  perfect;  for 
so  it  happened  in  a  case  which  I  saw  with  Mr  Bur- 
rowes,  in  Bishopsgate-sireet.  Mr  B.  paid  great  at- 
tention to  the  case,  and  the  patient  recovered  with- 
out any  diminution  of  the  natural  powers  of  the  part ; 
the  patella  being  gradually  forced  down  until  the 
ends  of  the  ligament  had  approximated  and  coalesced. 

Dislocation  downwards.  —  With  respect  to  dis- 
locations of  the  patella  downwards^  at  which  some 
surgeons  have  hinted,  I  have  seen  no  injury  which 
deserved  such  a  title,  if  I  except  a  rupture  of  the 
tendon  of  the  rectus,  which  1  have  twice  witnessed, 
and  which  destroyed  the  attachment  of  that  muscle 
to  the  patella.  The  appearance  of  this  injury  was 
a  soft  swelling  above  the  patella,  upon  which,  when 
the  hand  was  placed,  it  sunk  into  the  joint;  the 
patella  fell  loose  between  the  condyles  of  the  os 
femoris  and  the  head  of  the  tibia,  but  it  still  retained 
very  much  its  usual  situation,  and  could  not  be  said 
to  be  luxated,  as  it  was  not  displaced  from  the  joint. 

The  treatment  which  this  accident  requires  is, 
that  the  patient  be  obliged  to  preserve  a  sitting 
posture  during  the  cure;  and  that  a  cushion  be  ap- 
plied upon  the  ligamentum  patellas,  which  is  to  be 
confined  by  a  roller  passed  around  the  head  of  the 
tibia.* 

*  The  following  interesting  case  is  given  by  Mr  L.  Wheeler 
in  the  London  Quarterly  Journal  of  F.  Medicine,  No.  xii  : 

A  coal  heaver  fell  down,  and  the  fore  and  hinder  wheel  of  an 
empty  wagon,  passed  over  his  right  knee  in  a  direction  from  the 
inner  to  the  outside  of  the  joint.  Being  immediately  taken  to 
St  Bartholomew's  Hospital,  the  patella  was  found  resting  per- 
pendicularly on  its  internal  edge,  and  its  external  edge  was  in- 
clined directly  forwards,  so  that  its  upper  surface  was  turned 
inwards,  and  its  under  or  articulating  surface  turned  outwards. 
The  bone  was  placed  so  nearly  in  a  perpendicular  direction, 
that  its  upper  and  under  surfaces,  could  only  be  distinguished  by 


198 


DISLOCATIONS  OP  THE  KNEE. 


DISLOCATION   OF  THE  TIBIA  AT  THE  KNEE-JOINT. 

In  four  directions.  —  These  dislocations  occur  in 
four  different  directions;  but  two  of  them  are  in- 
complete, and  lateral,  while  the  others  are  perfect 
luxations,  the  tibia  being  thrown  either  backwards  or 
forwards. 

Internal.  —  The  lateral  dislocations  are  but  rare. 
In  the  dislocation  inwards  the  tibia  is  thrown  from 
its  situation,  so  that  the  condyle  of  the  os  femoris 
rests  upon  the  external  semilunar  cartilage,  and  the 
tibia  projects  on  the  inner  side  of  the  joint,  so  as  at 
once  to  disclose  the  nature  of  the  injury.  The  first 
case  of  this  kind  w^hich  I  ever  witnessed  was  brought 
to  St  Thomas's  Hospital  whilst  I  was  an  apprentice 
there,  and  I  remember  being  struck  with  three  cir- 
cumstances in  it :  the  first  was,  the  great  deformity 
of  the  knee  from  the  projection  of  the  tibia  ;  the 
second,  the  ease  with  which  the  bone  w^as  reduced 
by  direct  extension ;  and  the  third,  the  little  inflam- 
mation which  followed  upon  what  appeared  to  be  so 
serious  an  injury;  for  the  man  was  discharged  from 
the  hospital  after  a  few  weeks,  having  suffered  little 
local  or  no  constitutional  irritation. 

External.  —  The  tibia  is  sometimes  thrown  upon 
the  outer  side  of  the  knee-joint,  the  condyle  of  the 
OS  femoris  being  placed  in  the  situation  of  the  inner 
semilunar  cartilage,  or  rather  behind  it,  when  the 

comparison  with  the  superior  surface  of  the  opposite  patella. 
This  dislocation  was  suddenly,  but  with  some  difficulty  reduced 
by  bending  the  thigh  very  much  on  the  pelvis ;  drawing  the 
exterior  muscles  as  much  as  possible,  and  by  forcibly  raising 
the  bone  at  the  same  time  that  it  was  turned  in  its  natural  di- 
rection. J.  D.  G. 


DISLOCATIONS  OF  THE  KNEE. 


199 


same  deformity  is  produced  as  in  the  external  dis- 
location. The  reduction  of  the  limb  is  equally  easy 
with  the  former,  and  the  patient  recovers  with  little 
diminution  of  the  powers  of  the  part.  It  seems  to  me 
that  in  both  these  dislocations  the  tibia  is  rather  twist- 
ed upon  the  os  femoris,  so  that  the  condyle  of  the 
OS  femoris,  with  respect  to  the  tibia,  is  thrown  some- 
what backwards,  as  well  as  outwards  or  inwards.* 

Case,  —  One  of  the  aldermen  of  the  City  of  Lon- 
don, riding  down  Highgate-hiil  during  the  night,  and 
not  being  aware  of  a  rail  that  was  placed  across  a 
part  of  the  road,  which  was  undergoing  repair,  the 
horse  ran  against  the  rail,  and,  turning  quickly,  threw 
his  rider  over  it,  whilst  his  leg  was  confined  between 
the  rail  and  the  horse,  so  that  his  body  was  on  one 
side  of  the  rail,  and  his  leg  on  the  other:  the  result 
of  this  accident  was,  that  he  partially  dislocated  his 
tibia  outwards,  throwing  the  condyle  of  the  os  fe- 
moris inwards.  Being  immediately  taken  to  a  pub- 
lic-house, the  tibia  was  easily  replaced;  and  on  his 
removal  home,  some  hours  afterwards,  means  were 
used  to  reduce  the  swelling  and  inflammation,  which 
became  considerable.  When  he  attempted  to  bear 
upon  the  limb  he  found  the  capsular  ligament  very 
feeble,  and  he  was  obliged  to  have  a  knee-cap  made 
of  very  strong  leather,  to  support  and  connect  the 
bones ;  by  the  aid  of  this  bandage  he  gradually  re- 
covered, and  was  enabled  to  walk  well,  and  to  do 
duty  on  horseback  as  a  light-horse  volunteer,  before 
twelve  months  had  expired. 

*  I  have  seen  a  very  interesting-  case  of  dislocated  knee- 
joint  in  tlie  collection  of  my  friend,  Dr  Bond,  of  Philadelphia. 
The  leg  is  turned  entirely  round,  so  that  the  foot  is  placed  di- 
rectly outwards  —  the  heel  presenting  to  the  hollow  of  the 
other  foot,  and  the  articulation  of  the  knee  crossing  the  natural 
position  at  right  angles.  The  history  of  this  case  was  un- 
known ;  hut  from  all  appearances  the  limb  must  have  been  in 
this  situation  for  a  long  time  before  death.  J.  D.  G. 


200 


DISLOCATIONS  OF  THE  KNEE. 


Case  of  dislocation  inwards^  ~  1  was  consulted  by 
Mr  Richards  respecting  Mr  Bovill,  a  gentleman  from 
Barbadoes,  who  had  dislocated  his  knee.  I  made  a 
few  notes  on  the  case  at  the  moment,  which  were 
as  follow.  The  gentleman  was  thrown  from  a  gig; 
the  tibia  was  dislocated,  and  the  fibula  broken  a 
little  below  its  head.  The  head  of  the  tibia  pro- 
jected much  on  the  inner  side  of  the  condyle  of  the 
OS  femoris.  My  friends,  Mr  Caddell  and  Mr  Rich- 
ards, surgeons  at  Barbadoes,  saw  him  a  quarter  of 
an  hour  after  the  accident ;  the  leg  was  extended 
from  the  thigh-bone  in  a  bent  position  of  the  limb  ; 
the  extension  was  a  long  time  continued,  and  force 
was  employed  by  several  persons  for  half  an  hour 
before  the  luxation  was  reduced.  The  limb  became 
excessively  swollen,  and  remained  so  for  many  weeks, 
the  climate  probably  being  unfavourable  to  his  re- 
covery ;  but  at  length  the  inflammation  and  its  con- 
sequences were  subdued  by  local  depletion.  When 
I  saw  him  eighteen  months  had  elapsed  from  the 
accident,  and  he  could  not  then  bend  the  joint  at 
right  angles  with  the  thigh  ;  there  was  also  an  un- 
natural lateral  motion  of  the  joint,  from  the  injury 
which  the  ligaments  had  sustained.  The  fracture 
of  the  fibula  had  injured  the  peroneal  nerve,  as  w^as 
evident  from  the  numbness  of  which  he  complained 
in  the  outer  part  of  the  leg  and  foot. 

Dislocation  forwards,  — The  tibia  is  now  and  then 
dislocated  in  a  direction  forwards,  [n  this  accident, 
when  the  person  is  recumbent,  the  external  marks 
of  the  injury  are  these :  The  tibia  is  elevated  ;  the 
thigh-bone  is  depressed,  and  is  thrown  somewhat  to 
the  side  as  well  as  backwards;  the  os  femoris  makes 
such  pressure  on  the  popliteal  artery,  as  to  prevent  the 
pulsation  of  the  anterior  tibial  artery  on  the  foot  ; 
the  patella  and  tibia  are  drawn  by  the  rectus  muscle 
forwards.    Such  were  the  appearances  in  a  man  of 


DISLOCATIONS   OF  THE  KNEE. 


201 


the  name  of  Briggs,  brought  into  Guy's  Hospital  in 
the  year  i802,  not  only  with  this  accident,  but  with 
a  compound  fracture  of  the  tibia  of  the  other  leg,- 
with  dislocation  of  the  head  of  the  fibula.  Mr  Lu- 
cas was  obliged  to  amputate  the  compound  fracture, 
and  the  man  is  now  living  at  Walworth.  The  limb 
in  this  case  was  easily  reduced  by  extending  the 
thigh  from  above  the  knee,  and  by  drawing  the  leg 
from  the  thigh,  and  inclining  the  tibia  a  little  down- 
wards. As  soon  as  it  was  reduced,  the  popliteal 
artery  ceased  to  be  compressed,  and  the  pulsation  in 
the  anterior  tibial  artery  was  restored. 

Dislocation  backwards,  —  The  head  of  the  tibia  i& 
sometimes  dislocated  backwards,  behind  the  condyles 
of  the  OS  femoris,  producins:  the  following  appear- 
ances :  The  limb  shortened,  the  condyles  of  the  09 
femoris  projecting,  the  ligament  of  the  patella  de- 
pressed, and  the  leg  bent  forwards. 

For  the  following  case  I  am  indebted  to  my  judi- 
cious friend,  Dr  Walsh  man. 

Case  by  Dr  Walshman.  —  Mr  Luland,  residing 
near  the  Elephant  and  Castle,  at  Newington  Butts, 
a  very  robust  and  muscular  man,  on  the  4th  of 
January,  1794,  dislocated  his  shoulder  and  knee  at 
the  same  instant.  The  accident  happened  in  the 
following  manner  :  It  was  a  severe  frost,  and  the 
ground  very  slippery,  and  he  being  in  his  cart,  the 
horse  fell.  Mr  Luland  was  thrown  under  the  front 
rail  of  the  cart,  and  luxated  the  tibia  backwards, 
whilst  his  shoulder  fell  on  the  saddle,  and  dislocated 
the  OS  humeri  into  the  axilla.  The  head  of  the 
tibia  was  completely  dislocated  backwards,  reaching 
behind  the  condyles  of  the  femur  into  the  ham  ; 
the  tendinous  connexion  of  the  patella  to  the  rectus 
muscle  was  ruptured;  the  external  condyle  of  the 
OS  femoris  was  very  protuberant;  the  leg  was  bent 
forward  and  was  shortened,  and  there  was  a  deprea* 
26 


202 


DISLOCATIONS  OF  THE  KNEE. 


sion  just  above  the  patella.  The  patient  felt  most 
excruciatiijg  pain  when  the  limb  was  moved,  but 
there  was  not  any  considerable  degree  of  suffering 
when  it  was  at  rest.  Tiie  reduction  was  effected  in 
the  following  manner;  Two  men  extended  upwards, 
one  from  the  groin,  and  the  other  from  the  axilla, 
whilst  two  others  extended  the  leg  from  a  little 
above  the  ankle  in  the  opposite  direction ;  and  they 
gradually  increased  the  force  of  their  extension  till 
the  bone  was  reduced.  The  patient  was  placed  on 
his  back,  and  the  head  oi*  the  bone  was  directed  to 
its  natmal  situation.  A  flannel  roller  was  then 
applied  on  the  knee,  the  patient  placed  in  bed  with 
his  limb  upon  a  pillow,  and  the  part  directed  to  be 
kept  wet  with  an  evaporating  lotion.  He  remained 
in  this  state  a  fortniglit,  free  from  pain :  Dr  W. 
slightly  moved  the  part  every  other  day,  as  far  as 
he  could  without  giving  pain.  In  about  a  month 
Mr  Luland  began  to  walk  on  crutches.  Ten  weeks 
after  the  accident  he  was  able  to  sit  at  his  dinner- 
table,  and  in  five  inonths  he  had  given  up  the  use  of 
his  crutches,  and  appeared  perfectly  recovered,  being 
able  to  use  that  limb  as  well  as  the  other.  He  died 
of  dropsy  in  February,  1819. 

Dr  Walsh  man's  treatment  of  this  case  was  highly 
judicious.  He  suffered  the  parts,  as  he  observes  in 
his  letter,  to  remain  at  rest  till  the  adhesive  inflam- 
mation had  united  the  lacerated  ligament,  and  then, 
and  not  till  then,  began  with  passive  motion. 


PARTIAL    LUXATION    OF    THE    THIGH-BONE    FROM  THE 
SEMILUNAR  CARTILAGES. 

From  relaxation  ;  Mr  Hetfs  idea.  —  Under  ex- 
treme degrees  of  relaxation,  or  in  cases  in  which 


DISLOCATIONS  OP  THE  KNEE. 


203 


there  has  been  increased  secretion  into  a  joint,  the 
ligaments  become  so  much  lengthened,  as  to  allow 
the  cartilages  to  glide  upon  the  surface  of  the  tibia, 
and  particularly  when  pressure  is  made  by  the  thigh- 
bone on  the  edge  of  the  cartilage.  That  excellent 
practical  surgeon,  the  late  Mr  Hey,  of  Leeds,  was 
the  first  who  clearly  described  the  symptoms  and 
cause  of  these  accidents,  and  suggested  a  mode  of 
treatment  which  is  ingenious,  scientific,  and  generally 
successful.  The  injury  most  frequently  occurs  when 
a  person  in  walking  strikes  his  toe,  with  the  foot 
everted,  against  any  projection  (as  the  fold  of  a 
carpet),  after  which  he  immediately  feels  pain  in 
the  knee,  which  cannot  be  completely  extended.  I 
have  seen  this  accident  also  happen  from  a  person 
having  suddenly  turned  in  his  bed,  when  the  clothes 
not  suffering  the  foot  readily  to  turn  with  the  body, 
the  thigh-bone  has  slipped  from  its  semilunar  carti- 
lage. 1  have  also  known  it  occur  from  a  sudden 
twist  of  the  knee  inwards  when  the  foot  was  turned 
out. 

Explanation  of  the  accident,  8{c, — The  explana- 
tion of  this  accident  is  as  follows:  The  semilunar 
cartilages,  which  receive  the  condyles  of  the  os 
femoris,  are  united  to  the  tibia  by  ligaments,  and 
when  these  ligaments  become  extremely  relaxed 
and  elongated,  the  cartilages  are  easily  pushed  from 
their  situations  by  the  condyles  of  the  os  femoris, 
which  are  then  brought  into  contact  with  the  head 
of  the  tibia;  and  when  the  limb  is  attempted  to  be 
extended,  the  edges  of  the  semilunar  cartilages  pre- 
vent it.  How  then  is  the  bone  to  be  ag^ain  brousfht 
upon  the  cartilages?  Why,  as  Mr  Hey  has  advis- 
ed, by  bending  the  limb  back  as  far  as  is  possible, 
which  enables  the  cartilage  to  slip  into  its  natural 
situation;  the  pressure  of  the  thigh-bone  is  removed 
in  the  bent  position,  and  the  leg  being  brought  for- 


204 


DFSLOCATIONS  OF  THE  KNEE. 


wards,  it  can  then  be  completely  extended,  because 
the  condyles  of  the  os  femoris  are  again  received 
on  the  semilunar  cartilages.  This  plan  is  not,  how- 
ever, invariably  successful,  as  the  following  case  will 
show.  A  lieutenant  in  the  ai  rnv  suifered  this  acci- 
dent  repeatedly,  and  the  limb  was  as  often  reduced 
by  the  above  means;  but  at  length  turning  in  bed, 
from  the  pressure  of  the  bed  clothes  on  his  foot, 
the  accident  recurred.  He  came  to  town;  but 
bending  the  limb  had  now  no  effect  in  enabling  him 
to  extend  the  joint,  I  therefore  advised  him  to  visit 
Mr  Hey,  at  Leeds;  but  I  learnt  that  in  this  case  the 
dislocation  was  never  reduced. 

Different  mode  of  reduction.  —  I  made  the  follow- 
ing notes  of  the  case  of  a  gentleman  who  came  to 
my  house.  Mr  Henry  Dobley,  aged  thirty-seven, 
has  often  dislocated  his  knee,  turning  the  foot  in- 
wards and  the  thigh-bone  outwards,  by  accidentally 
slipping  on  uneven  ground,  or  by  sudden  exertions 
of  the  limb;  considerable  pain  Avas  immediately 
produced,  accompanied  with  a  great  deal  of  swelling. 
His  mode  of  reducing  it  is  as  follows:  He  sits  upon 
the  ground,  and  then  bending  the  thigh  Inwards  and 
pulling  the  foot  outwards,  the  subluxation  of  the  os 
femoris  being  external,  tlie  natural  position  of  the 
limb  becomes  restored.  A  knee-cap  laced  tightly 
around  the  knee,  is  (he  usual  preventive  of  the  re- 
turn of  this  accident ;  but  it  is  not  sufficient  in  Mr 
Dobley  without  the  addition  of  straps,  and  more 
especially  of  a  very  strong  one  of  leather,  just  below 
the  patella. 

Particular  bandage  required.  A  young  lady  was 
brought  to  my  house  who  was  frequently  the  subject 
of  this  accident,  but  in  her  the  cartilages  liad  been 
several  times  easily  replaced,  and  the  return  of  the 
accident  prevented  by  a  bandage  composed  of  a 
piece  of  linen  with  four  rollers  attached  to  it,  which 


DISLOCATIONS  OF  THE  KNEE. 


205 


were  tightly  bound  above  and  below  the  patella  ; 
this,  she  said,  answered  its  intended  purpose  better 
than  any  other  contrivance. 

In  some  of  these  cases  orreat  alteration  takes 
place  in  the  form  and  size  of  the  knees,  from  a 
chronic  rheumatism  occasionally  attending  them.  1 
made  the  following  notes  of  a  case  of  this  kind  on 
which  I  was  consulted,  and  I  have  seen  others  of 
similar  character. 

Case,  —  Lady  D.,  a  year  and  a  half  ago,  fell  and 
twisted  her  thigh-bone  inwards  at  the  knee,  produc- 
ing great  pain  on  the  inner  side  of  the  joint.  Her 
ladyship  immediately  restored  the  parts  to  their 
situation  by  pressing  the  thigh  outwards  and  the  leg 
inwards,  previously  to  which  she  could  not  move 
the  joint.  For  a  fortnight  she  was  scarcely  able  to 
bend  or  straighten  the  knee,  and  the  muscles  felt 
to  her  to  be  in  a  state  of  cramp.  She  then  began 
to  stand  upon  the  limb  by  the  aid  of  crutches,  but 
when  she  bore  upon  it  considerably,  it  suddenly 
bent  back,  with  pain  and  subsequent  swelling,  and 
she  felt  the  condyles  at  the  same  time  slip  from  the 
semilunar  cartilages  upon  the  head  of  the  tibia. 
Any  sudden  motion  produced  the  same  etTect  for 
fifteen  months,  and  each  of  these  accidents  retarded 
her  recovery  for  several  weeks;  the  pain  extended 
from  the  knee  to  the  toe.  For  three  months  pre- 
vious to  her  last  accident  she  walked  on  crutches, 
and  even  sometimes  with  only  the  aid  of  a  stick  ; 
but  about  two  months  since,  in  endeavouring  to 
raise  herself  from  a  sofa,  the  left  knee  gave  way 
as  if  the  bone  had  slipped  from  its  place,  the  thigh- 
bone being  at  the  time  twisted  outwards;  pain  and 
swelling  succeeded,  and  she  has  never  been  able 
to  stand  upright  since.  Her  joints  are  all  of  them 
remarkably  flexible,  as  the  elbow  may  be  easily 
bent  backwards  to  form  an  angle  with  the  os  hu- 


206 


DISLOCATIONS  OF  THE  KNEE. 


meri.  When  a  girl,  she  had  frequently  the  sensa- 
tion of  putting  the  knees  out  of  joint,  but  they 
soon  got  well.  The  knees  are  now  swollen,  and 
effusion  of  a  considerable  quantity  of  synovia  has 
taken  place  into  the  joints.  When  she  attempts  to 
stand  she  cannot  straighten  her  knees,  but  would 
fall  forwards  if  unsupported.  The  principal  object 
in  the  treatment  is,  to  produce  absorption  of  the 
fluid  which  is  effused,  and  then  give  due  support 
to  the  ligaments.  For  the  first  of  these  she  was 
desired  to  apply  blisters,  which  were  directed  to  be 
kept  discharging  for  a  considerable  time,  and  after 
they  were  healed,  she  was  ordered  to  make  pres- 
sure upon  the  joints  by  a  strong  bandage,  which 
was  to  be  occasionally  removed  to  give  an  oppor- 
tunity of  employing  friction.  But  she  received  ma- 
terial benefit  from  a  constitutional  treatment,  con- 
sisting of  pll.  hydrargyri  submuriatis  corop.,  with 
decoctum  sarsaparillae  compositum,  and  locally  from 
the  continued  use  of  friction.  I  have  had  lately 
the  pleasure  of  seeing  her  perfectly  recovered. 

In  the  dissection  of  these  cases,  the  ligament  is 
found  extremely  thickened ;  little  pendulous  liga- 
mentous and  cartilaginous  bodies  are  seen  suspend- 
ed from  it ;  a  thick  edge  of  cartilage  projects  from 
the  articular  cartilage,  and  a  part  of  the  latter  is 
absorbed.  When  the  bone  is  macerated,  a  great 
addition  of  ossific  matter  is  found  to  have  been 
made  to  the  edges  of  the  condyles  of  the  os  fe- 
moris, 


DISLOCATION  OF  THE  KNEE-JOINT. 


Cases  of  dislocation  of  the  knee-joint  are  so  rare, 
that  every  instance  of  this  accident  is  worthy  of 


DISLOCATIONS  OF  THE  KNEE. 


207 


recital ;  and  I  feel  greatly  indebted  to  my  friend, 
Mr  Toogood,  surgeon  at  Bridgewater,  for  the  fol- 
lowing detail  of  one  which  occurred  under  his  care. 

Decewher  5th^  1806. 
Case,  —  Francis  Newton,  a  strong  athletic  man, 
thirty  years  old,  fell  from  the  fore  part  of  a  wagon, 
heavily  laden  with  coals,  and  entangling  his  foot  in 
the  frame-work  of  the  shaft,  was  dragged  for  a  very 
great  distance  before  he  was  released.  1  saw  him 
two  hours  after  the  accident.  The  left  knee  was 
very  much  swollen;  the  tibia,  fibula,  and  patella 
were  driven  up  in  front  of  the  thigh;  and  the  os 
femoris  occupied  the  upper  part  of  the  calf  of  the 
leg,  the  internal  condyle  being  nearly  through  the 
skin.  It  was  a  complete  dislocation,  and  the  ap- 
pearance of  the  limb  so  dreadful,  that  I  despaired  of 
being  able  to  reduce  it ;  but,  to  my  surprise,  it  was 
more  easily  effected  than  I  imagined.  By  placing 
two  men  to  the  thigh  whilst  I  extended  the  leg,  the 
man  became  directly  relieved.  The  whole  limb 
was  placed  in  splints,  and  the  strictest  antiphlogistic 
treatment  observed,  with  the  most  perfect  quiet. 
The  symptoms  were  very  mild  ;  and,  by  carefully 
watching  him,  he  suffered  very  little  inflammation  or 
pain.  At  the  expiration  of  a  month  I  allowed  him 
to  get  up,  and  on  the  29th  of  January,  he  came  into 
this  town,  a  distance  of  four  miles,  in  a  cart,  and 
walked  from  an  inn  to  my  house,  with  his  leg  but 
little  swollen,  and  having  some  motion  of  the  joint. 
He  eventually  recovered  a  very  good  use  of  his  limb, 
and  walks  with  so  little  inconvenience  that  he  has 
followed  his  business  as  a  wagoner  ever  since ;  and 
this  day,  November  30th,  1822,  I  have  seen  him 
walking  by  the  side  of  his  team  Avith  very  little 
lameness. 


*208  DISLOCATIONS   OF  THE  KNEE. 


COMPOUND   DISLOCATION  OF  THE  KNEE-JOINT. 

Having  seen  only  one  instance  of  this  dislocation, 
I  conclude  it  to  be  a  rare  occurrence  ;  and  there  are 
scarcely  any  injuries  incident  to  the  body  which 
more  imperiously  demand  immediate  amputation 
than  these. 

Case.  —  On  Monday,  August  26th,  1819,  at  eleven, 
p.  m.,  I  was  sent  for  by  Mr  Oliver,  surgeon,  at 
Brentford,  to  visit  Mr  Pritt,  who  had  fallen  from 
the  box  of  a  mail  coach,  and  most  severely  injured 
his  knee.  1  met,  at  the  house  to  which  he  was 
carried,  Mr  Oliver,  and  Mr  Hunter,  of  Richmond, 
surgeons,  and  immediately  proceeded  to  examine  the 
knee.  A  large  opening  was  found  in  the  integuments, 
through  which  the  external  condyle  of  the  os  femoris 
projected,  so  as  to  be  on  a  level  with  the  edges  of 
the  skin.  The  os  femoris  was  thrown  behind  the 
tibia  on  the  outer  side  of  the  head  of  the  latter,  and 
the  external  condyle  of  the  thigh-bone  was  dislo- 
cated backwards  and  outwards  ;  the  thigh-bone  was 
twisted  outwards,  and  the  internal  condyle  advanced 
upon  the  head  of  the  tibia.  I  made  attempts  to  re- 
duce the  condyle,  but  it  could  only  be  effected  with 
extreme  difficulty;  and  the  bone,  directly  when  the 
extension  was  removed,  slipped  into  its  former  situa- 
tion. The  joint  being  freely  opened  by  the  accident, 
the  bone  dislocated,  and  when  reduced  easily  slipping 
from  its  place,  and  the  patient  having  an  extremely 
irritable  constitution,  I  determined  at  once  to  pro- 
pose the  amputation  of  the  limb,  which,  being  acced- 
ed to,  was  immediately  performed.  The  symptoms 
of  constitutional  irritation  which  followed  the  opera- 
tion became  extremely  severe,  and  he  being  delirious 
on  the  31st,  Mr  Oliver  applied  leeches  to  his  tern- 


DISLOCATIONS   OF  THE  KNEE. 


209 


pies,  a  blister  under  the  occiput,  and  gave  the  saline 
medicine  with  the  camphor,  and  the  pulv.  ipec.  comp. 
On  the  following  day  I  was  sent  for  to  visit  him,  but 
being  absent  from  London,  my  vahied  friend,  Mr 
Cline,  visited  him,  and  ordered  him  tine.  opii.  gtt.  v. 
—  Pulv.  castor.  gr.  x. —  Mist,  camphor.  3iss.  m. — 
Ft.  haustus  4ta  quaque  hora  sumendus.  Soon  after 
the  second  draught  w^as  administered  he  fell  asleep, 
and  after  several  hours  repose  awoke  perfectly  sen- 
sible* He  gradually  recovered,  and  left  Brentford 
on  the  25th  of  October,  with  a  small  wound  still  re- 
maining on  the  stump. 

Dissection.  —  I  brought  home  the  limb,  and  care- 
fully dissected  it.  Under  the  skin  there  was  great 
extravasation  of  blood  in  the  cellular  membrane 
surrounding  the  knee  ;  the  vastus  internus  muscle 
had  a  large  aperture  torn  in  it  just  above  its  insertion 
into  the  patella  ;  the  tibia  projected  forwards  ;  and 
the  patella  was  drawn  to  the  outer  side  of  the  knee, 
being  no  longer  in  a  line  with  the  tubercle  of  the 
tibia.  Looking  at  the  joint  posteriorly,  both  heads 
of  the  gastrocnemius  externus  muscle  were  lacerat- 
ed ;  the  capsular  ligament  was  so  completely  torn, 
posteriorly,  that  both  the  condyles  of  the  os  femoris 
were  seen  projecting  through  the  laceration  in  the 
gastrocnemius  ;  neither  the  sciatic  nerve,  the  pop- 
liteal artery  and  vein,  the  lateral,  nor  the  crucial 
ligaments,  were  ruptured.    (See  Plate,) 

It  is  probable  that  all  compound  dislocations  of 
the  knee-joint  will  require  a  similar  practice,  unless 
the  wound  be  so  extremely  small  as  to  admit  readily 
of  its  immediate  closure  and  adhesion^ 
27 


210 


DISLOCATIONS  OF  THE  KNEE. 


DISLOCATION  OF  THE  KNEE  FROM  ULCERATION. 

Ligament  ulcerated,  —  In  the  progress  of  chronic 
diseases  of  the  joints,  inflammation  beginning  in  the 
synovial  membrane,  and  proceeding  to  ulcerate  the 
articular  cartilages  and  bone,  at  length  affect  the 
capsular  ligament,  and  sometimes  even  the  peculiar 
ligaments  of  the  joints;  the  bones  thus  becoming 
unconnected,  the  muscles  irritated  by  participating 
in  the  inflammation,  draw  the  limb  into  distorted 
positions,  and  thus  one  bone  becomes  gradually  dis- 
placed from  the  other.  This  state  is  most  frequent- 
ly seen  in  the  hip-joint,  from  the  oblique  bearing  of 
the  thigh-bone  on  the  pelvis.  In  the  knee  it  is  also 
not  unusual  that  the  thigh-bone  shall  be  placed  out 
of  its  natural  line  with  the  tibia,  projecting  either  on 
the  one  side  or  the  other. 

Excessive  distortion,  —  Now  and  then  most  re- 
markable distortions  are  produced  by  the  irritative 
and  spasmodic  action  of  the  muscles  succeeding  the 
ulcerative  process  of  the  ligaments,  of  one  of  which 
I  have  given  a  plate ;  Mr  Cline  removed  it  by 
amputation  in  St  Thomas's  Hospital.  It  had  been 
the  consequence  of  what  is  vulgarly  called  the 
white  swelling  of  the  knee-joint;  the  leg  was  placed 
forwards  at  right  angles  with  the  thigh,  so  that  when 
walking  on  his  crutches  he  had  the  most  grotesque 
appearance,  as  the  bottom  of  his  foot  first  met  the 
.  eye  when  he  was  advancing.  Upon  inspection  of 
the  patella  it  was  found  anchylosed  to  the  os  femo- 
ris,  and  the  tibia  was  also  joined  by  ossific  union  to 
the  fore  part  of  the  condyles  of  the  thigh-bone. 
{See  Plate.) 

How  prevented,  —  This  state  of  parts  may  be  pre- 
vented by  opposing  the  action  of  the  muscles  when 
their  irritability  first  begins  to  produce  distortion  ; 


DISLOCATIONS  OF  THE  KNEE. 


21 1 


by  the  application  of  splints ;  and  by  the  exhibition 
of  the  pulvis  ipecacuanhas  compositus,  to  diminish 
the  irritabihty  of  the  system.  Thus  I  have  seen, 
in  cases  of  ulceration  of  the  hip-joint,  the  irritative 
action  of  the  flexor  muscles  diminished,  and  future 
distortion  prevented,  by  drawing  down  the  limb  and 
keeping  it  in  the  extended  position  ;  but  as  this  ex- 
tension is  most  painful  to  the  patient,  however  de- 
sirable it  may  be,  it  should  be  accomplished  very 
gradually. 


FRACTURES  OF  THE  KNEE-JOINT. 


I  SHALL  now,  pursuing  my  former  plan,  describe 
the  fractures  to  which  the  bones  entering  into  the 
composition  of  this  part  are  liable  ;  and  first  the 

FRACTURES   OF  THE  PATELLA. 

Transverse  or  longitudinal.  —  This  bone  is  gen- 
erally broken  transversely,  sometimes,  though  rarely, 
longitudinally  :  it  is  liable  also  to  simple  and  com- 
pound fracture  ;  but,  fortunately,  the  latter  is  but 
of  rare  occurrence. 

Symptoms. — When  the  patella  is  transversely 
broken,  the  upper  part  of  the  bone  is  drawn  from 
the  lower,  its  superior  portion  being  elevated  by 
the  action  of  the  rectus,  vasti,  and  cruralis  muscles, 
which  are  inserted  into  its  upper  part;  whilst  the 
lower  portion  is  still  retained  in  its  natural  situation 
by  the  ligament  which  passes  from  it  to  the  tuber- 
cle of  the  tibia. 

Degree  of  separation,  —  The  degree  of  separation 
thus  produced,  depends  on  the  extent  of  laceration 


FRACTURES   OF    THE  KNEE. 


213 


of  the  ligament;  for  when  the  ligament  is  but  lit- 
tle torn,  the  separation  will  be  half  an  inch,  but 
under  great  extent  of  injury  the  bone  is  drawn  five 
inches  upwards,  the  capsular  ligament  and  tendi- 
nous aponeurosis  covering  it  being  then  greatly  lac- 
erated ;  and  this,  with  one  exception,  is  the  great- 
est extent  of  separation  which  I  have  seen.  The 
accident  may  be  at  once  known  by  the  depression 
between  the  two  portions  of  bone;  the  fingers  pass- 
ing readily  down  to  the  condyles  of  the  os  femoris, 
into  the  joint  as  far  as  the  integuments  will  permit; 
and  the  elevated  portion  of  bone  moving  readily 
on  the  lower  and  fore  part  of  the  thigh.  The 
power  of  extending  the  limb  is  lost  immediately  af- 
ter the  accident,  and  likewise  that  of  supporting  the 
weight  of  the  body  on  that  leg,  if  the  person  be 
standing ;  for  the  knee   bends  forwards  from  the 
loss  of  action  in  the  extensor  muscles.    The  pain 
of  this  accident  is  not  very  severe,  and  a  simple 
fracture  is  not  dangerous,  for  the  constitution  feels 
it  but  little.    In  a  few  hours  after  the  accident,  a 
copious  extravasation  of  blood  takes  place  upon  the 
fore  part  of  the  joint,  so  that  the  appearance  is 
livid  from  ecchymosis,  but  this  is  removed  by  ab- 
sorption in  a  few  days.    Considerable  inflammation 
and  fever  succeed,  and  there  is  a  great  degree  of 
swelling  in  the  fore  part  of  the  joint,  both  from 
the  free  secretion  of  synovia,  and  the  effusion  aris- 
ing from  inflammation.    No  crepitus  is  felt  in  this 
fracture,  for  the  bones  cannot   be  sufficiently  ap- 
proximated to  evince    this  general  discriminating 
mark  of  other  fractures. 

The  separation  of  the  bones  is  much  increased 
by  bending  the  knee,  as  this  act  removes  the  lower 
from  the  upper  portion  of  bone,  pulling  down  the 
tibia,  the  ligamentum  patellar,  and  the  lower  part 
of  the  bone  from  the  upper» 


214 


FRACTURES   OF  THE  KNEE. 


Causes,  Src.  —  The  accident  arises  from  two  caus- 
es: first,  from  blows  upon  the  bone  produced  by 
falls  upon  the  knee,  or  received  upon  the  patella 
in  the  erect  position  of  the  body;  and,  secondly, 
from  the  action  of  the  extensor  muscles  upon  the 
bone. 

Case.  —  A  gentleman  walking  in  the  country,  and 
not  used  to  jumping,  leaped  a  ditch  of  considerable 
breadth  ;  and  when  he  reached  the  opposite  bank, 
being  in  danger  of  falling,  he  ran  forward  several 
steps,  and  Avith  difficulty  recovered  himself;  in  this 
attempt  to  save  himself  from  a  fall,  he  felt  the  pa- 
tella snap.  I  was  sent  for  to  him,  and  found  his 
patella  broken,  and  the  portions  of  bone  consider- 
ably separated. 

A  lady,  descending  some  stairs,  placed  her  heel 
near  the  edge  of  one  of  the  stairs,  and  was  in  dan- 
ger of  falling  forwards,  when,  throwing  her  body 
somewhat  backwards  to  prevent  the  fall  and  to 
straighten  the  knee,  the  patella  became  broken. 

Explanation. — That  a  bone  should  thus  break 
by  the  action  of  muscles  appears  at  first  sight  in- 
comprehensible, but  this  circumstance  is  easily  ex- 
plained. When  the  knee  is  bent,  the  patella  is 
drawn  down  on  the  end  of  the  condyles  of  the  os 
femqris,  so  as  to  bring  the  upper  edge  of  the  bone 
forwards ;  and  at  that  moment  it  is  that  the  patella 
is  broken,  by  the  rectus  muscle  acting  not  in  a  line 
with  the  bone,  but  at  right  angles  with  it,  or  nearly 
so,  and  upon  its  upper  edge  more  particularly. 

Mode  of  union. — With  respect  to  the  union  of  this 
bone,  whether  the  separation  be  great  or  inconsider- 
able, it  is  generally  effected  by  an  intervening  liga- 
mentous substance.  The  bone  itself  undergoes  but 
little  alteration;  the  lower  portion,  joined  by  liga- 
ment to  the  patella,  has  its  broken  cancellated  struc- 
ture still  apparent,  although  a  little  smoothed.  The 


FRACTURES    OF   THE  KNEE. 


215 


upper  portion  of  bone  has  its  broken  cancelli  covered 
by  a  slight  ossific  deposit,  so  that  there  is  more  ossific 
action  in  the  upper  than  in  the  lower  portion  of  the 
bone,  and  certainly  much  less  than  in  bones  which 
do  not  form  a  part  of  the  joints.  The  internal  arti- 
cular surface  of  the  bone  preserves  its  natural  smooth- 
ness. Blood  is  immediately  deposited  in  the  place 
of  the  injured  ligament,  but  this  in  a  few  days  is  ab- 
sorbed. Inflammation  arises  and  pours  out  adhesive 
matter,  which  extends  from  one  edge  of  the  lacer- 
ated ligament  to  the  other,  and  even  between  the 
bones,  to  each  of  which  it  is  firmly  united.  (See 
Plate.)  Vessels  shoot  from  the  edges  of  the  liga- 
ment and  render  the  new  substance  organized,  pro- 
ducing a  ligamentous  structure  similar  to  that  from 
which  the  vessels  shoot  ;  this  substance  is  not,  how- 
ever, always  perfect,  for  I  have  seen  apertures  in 
it;  but  this  will  greatly  depend  upon  the  extent  of 
the  laceration  of  the  ligament,  and  the  too  early  use 
of  the  limb.  In  the  dog  and  in  the  rabbit, or  almost 
any  other  quadruped,  it  is  possible  by  experiment  to 
trace  the  mode  of  union  of  this  bone. 

Experiment  I. 
I  drew  the  integuments  much  aside  in  a  rabbit, 
and  dividing  them,  placed  a  knife  upon  the  patella 
and  struck  it  lightly  with  a  mallet  ;  the  bone  was 
broken  and  directly  drawn  up  by  the  action  of  the 
muscles.  I  let  the  integuments  go,  and  the  wound 
was  not  opposite  to  the  fracture.  In  forty-eight 
hours  I  killed  the  animal  and  examined  the  part: 
the  bones  were  separated  three-quarters  of  an  inch, 
and  the  intervening  part  filled  with  coagulated 
blood. 

Experiment  II, 
I  repeated  the  former  experiment,  and  having 


216 


FRACTURES  OF   THE  KNEE. 


killed  the  animal  on  the  eighth  day,  found  most  of 
the  blood  absorbed,  and  adhesive  matter  occupying 
the  space  between  the  bo^es. 

Experiment  III. 
The  former  experiment  repeated.    The  animal 
examined  on  the  fifteenth  day.    The  adhesive  mat- 
ter had  acquired  a  smooth  and  somewhat  hgament- 
ous  character. 


Experiment  IV, 
The  same  division  of  the  bone  being  made,  it  was 
examined  on  the  twenty-second  day,  when  the  new 
ligament  was  complete. 

Experiment  V. 

The  same  repeated,  and  the  examination  made  in 
five  weeks.  The  part  was  injected,  and  vessels 
were  found  proceeding  from  the  edge  of  the  ligament 
into  the  adhesive  matter,  now  become  ligamentous. 
So  that  at  the  end  of  five  weeks  the  vascularity  is 
complete,  and  some  vessels  proceed  into  the  new 
ligament  from  the  bone,  but  chiefly  from  the  lacer- 
ated ligament.  Upon  the  dog  these  processes  may 
be  equally  well  observed,  but  they  are  not  quite  so 
rapidly  produced  in  a  large  dog  as  in  the  rabbit. 

The  parts  were  dissected  and  preserved  after 
these  experiments,  both  in  the  dog  and  rabbit,  and 
they  are  deposited  in  the  collection  of  St  Thomas's 
Hospital,  where  they  may  always  be  seen. 

Experiment  VI. 
In  the  rabbit,  having  dividecj  the  bone,  I  sewed 
the  two  portions  by  conveying  a  needle  and  thread 
through  the  tendinous  covering  of  the  bone,  but  the 


FRACTURES  OF  THE  KNEE. 


217 


ligatures  separated,  and  the  bones  still  united  by 
ligament. 

Experiment  VII. 

I  divided  the  bone,  and  cut  the  rectus  muscle 
across  above  it,  yet  the  patella  united  by  ligament. 

I  could  not,  either  in  the  dog  or  rabbit,  succeed  in 
producing  a  bony  union  in  the  transverse  fracture. 
Yet  in  a  patient  of  my  kind  friend,  M.  Chopart,  at 
Paris,  I  once  saw  a  case  which  appeared  to  me  to  be 
united  by  bone  ;  and  Mr  Fielding,  of  Hull,  has  lately 
published  a  similar  case. 

Liigamentous  union  as  short  as  possible,  —  A  liga- 
mentous union  of  the  transverse  fracture  of  the  pa- 
tella is  that  which  generally  occurs  ;  and  if  there 
be  an  exception  it  is  very  rare.  But  still  the  prin- 
ciple which  is  to  guide  the  surgeon's  conduct  is,  to 
make  that  ligament  as  short  as  possible.  If  the  liga- 
ment be  of  great  length  there  is  a  proportionate 
weakness;  for  as  soon  as  the  accident  has  happened, 
the  rectus  muscle  retracts  and  draws  up  the  superi- 
or portion  of  the  patella;  and  in  proportion  as  the 
retraction  is  suffered  to  continue  the  muscle  is  short- 
ened and  its  power  consequently  diminished.  Those, 
therefore,  in  whom  the  bones  have  united  after 
being  widely  separated,  if  they  walk  quickly,  do  it 
with  a  halt,  and  are  very  liable  to  fall,  and  to  break 
the  other  patella.  Let  then  the  muscle  be  brought  as 
nearly  as  it  can  be  to  its  natural  length  ;  and  although 
complete  apposition  of  the  bone  may  be  very  rarely 
effected,  yet  the  ligamentous  union  will  be  rendered 
as  short  as  circumstances  will  permit,  and  the  patient 
will  recover  the  power  of  the  limb. 

The  notion  which  was  formerly  entertained  of  the 
danger  of  squeezing  the  callus  into  a  projection  in  the 
inner  side  of  the  bone,  so  as  to  destroy  the  smooth- 
ness of  its  internal  surface,  is  not  at  all  tenable, 
.28 


218 


FRACTURES  OP  THE  KNEE. 


Treatment,  —  When  called  to  this  accident,  the 
surgeon  places  the  patient  in  bed  upon  a  mattress, 
extends  the  limb  upon  a  well  padded  splint  placed 
behind  the  thigh  and  leg,  to  which  it  is  tied,  and 
which  should  be  hollowed.  The  patient's  body 
should  be  raised  as  much  as  he  can  bear  to  the  sit- 
ting posture,  to  relax  the  rectus  muscle.  An  evapo- 
rating lotion  is  to  be  then  applied  upon  the  knee, 
consisting  of  liq.  plumbi  s.  acetat.  dilut.  3.  v.  with 
spir.  vini.  3.  i. ;  and  no  bandage  should  be  at  first 
employed.  The  body  should  be  slightly  raised  in 
bed  to  relax  the  rectus  muscle,  and  the  heel  should 
be  raised  to  bring  up  the  lower  portion  of  the  patella. 
If  in  a  day  or  two  there  be  much  tension  or  ecchymo- 
sis,  leeches  should  be  applied,  and  the  lotion  be  con- 
tinued; after  a  few  days,  when  the  tension  has  sub- 
sided, and  not  till  then,  should  bandages  be  employed. 
I  have  seen  the  greatest  suffering  and  swelling  pro- 
duced by  the  early  application  of  bandages  in  these 
cases,  even  so  as  to  threaten  sloughing  of  the  skin 
when  there  had  been  much  contusion.  The  means 
which  are  most  frequently  employed  in  the  treat- 
ment of  this  case  are  the  following:  A  roller  is  ap- 
plied from  the  foot  to  the  knee,  to  prevent  the  swell- 
ing of  the  leg,  and  the  upper  portion  of  bone  is 
pressed  downwards,  as  far  as  it  can  be  without  vio- 
lence towards  the  lower,  so  as  to  lessen  the  retrac- 
tion of  the  muscles,  and  produce  the  approximation 
of  the  portions  of  bone.  Then  rollers  are  applied 
above  and  below  the  joint,  confining  a  piece  of  broad 
tape  next  the  skin  on  each  side,  which  crosses  the 
rollers  at  right  angles  ;  these  portions  of  tape  are 
bent  down  and  tied  over  the  rollers  so  as  to  bring 
them  near  each  other,  and  thus  to  keep  down  the 
upper  portion  of  bone.  Sometimes,  instead  of  the 
tape  on  each  side,  a  broad  piece  of  linen  is  bent  over 
the  rollers  on  the  fore  part  of  the  joint,  and  is  there 


FRACTURES  OF  THE  KNEE.  219 

confined,  so  as  to  approximate  the  pieces  of  bone, 
and  to  bind  down  the  upper  portion  of  the  patella, 
that  its  lower  broken  edge  may  not  turn  forwards. 

But  the  mode  I  prefer  is  as  follows  :  A  leather 
strap  should  be  buckled  around  the  thigh,  above  the 
broken  and  elevated  portion  of  bone  ;  and  from  this 
circular  piece  of  leather  another  strap  should  be 
passed  under  the  middle  of  the  foot,  the  leg  being 
extended,  and  the  foot  raised  as  much  as  possible. 
This  strap  is  brought  upon  each  side  of  the  tibia 
and  patella,  and  buckled  to  that  which  is  fixed  around 
the  lower  part  of  the  thigh.  The  strap  may  be 
confined  to  the  foot  by  a  tape  tied  to  it,  and  to  the 
leg  at  any  part  in  the  same  manner;  this  is  the  most 
convenient  bandage  for  the  fractured  patella,  and 
for  the  patella  dislocated  upwards  by  the  laceration 
of  its  ligament.    A  roller  is  to  be  applied  upon  the 

In  this  position,  and  thus  confined,  the  limb  is  to 
be  kept  for  five  weeks  in  the  adult,  and  for  six  weeks 
at  a  more  advanced  age.  Then  a  slight  passive  mo- 
tion is  to  be  begun,  and  this  must  be  done  gently  and 
with  so  much  circumspection  that  the  ligament,  if 
not  firmly  united,  shall  not  give  way,  and  suffer  the 
bones  to  recede.  If  the  union  be  found  sufficiently 
firm  to  bear  it,  the  passive  motion  is  to  be  employ- 
ed, from  day  to  day,  until  the  flexion  of  the  limb  be 
complete. 

State  of  the  muscle,  —  If  passive  motion  were  not 
used  it  is  to  be  apprehended  that  the  action  of  the 
extensor  muscles  would  never  return  ;  for  those  who 
are  kept  in  bed,  with  the  joint  at  rest,  do  not  in 
many  months  acquire  any  power  of  bending  and  ex- 
tending the  limb.  When  this  motion  becomes  ex- 
pedient the  patient  is  placed  on  a  high  seat,  and  di- 
rected to  swing  the  leg,  by  which  motion  is  given  to 
the  rectus;  and  if  the  mind  be  then  directed  to  the 


220 


FRACTURES  OF  THE  KNEE. 


contraction  of  that  muscle,  its  powers  will  be  gra- 
dually renewed.  When  the  rectus  muscle  has  been 
shortened,  and  the  upper  portion  of  bone  is  drawn 
from  the  lower,  all  the  disposition  to  action  in  that 
muscle  ©eases  ;  and  it  does  not  seem  disposed  to  re- 
cover its  voluntary  action  until  it  becomes  again 
elongated,  which  effect  takes  place  after  the  union 
of  the  ligament  by  bending  the  knee  ;  and  from  this 
point  of  elongation  the  muscle  begins  to  contract. 

A  young  woman  was  brought  into  my  house  in  her 
father's  arms,  and  he  said,  '  I  am  obliged  to  carry 
her,  for  she  has  lost  the  use  of  her  legs,  having  bro- 
ken both  her  knee-pans  eight  months  ago,  and  she 
has  never  been  able  to  use  her  limbs  since.'  Pas- 
sive motion  was  directed,  and  she  was  ordered  to 
try  to  extend  her  legs  after  they  had  been  bent  by 
the  surgeon.  At  first  she  could  effect  but  little : 
however,  by  repeated  trials,  she  gradually  recovered 
the  use  of  her  limbs.  Mr  John  Hunter,  who  raised 
surgery  into  a  science,  and  seems  to  have  been  the 
first  who  attended  to  the  principles  on  which  the 
practice  of  surgery  ought  to  be  regulated,  always 
dwelt  most  ably  upon  this  subject  in  his  lectures. 
Patients,  from  the  pain  which  passive  motion  pro- 
duces, and  the  slow  return  of  action  in  the  muscles, 
are  indisposed  to  suffer  the  one  or  to  make  trial  of 
the  other;  but  without  them  there  can  be  no  re- 
covery. 

Degree  of  approximation, —  The  degree  of  approxi- 
inflation  of  the  bone  is,  as  I  have  stated,  a  matter  of 
great  consequence.  The  bone  is  rarely  brought 
into  contact  so  as  to  be  united  in  the  transverse 
fracture  by  ossific  union,  but  the  less  the  distance 
between  the  bones  the  greater  is  the  power  which 
the  muscle  re-acquires;  for  in  proportion  as  the  mus- 
cle is  shortened  it  is  weakened;  and  in  ascending 
there  is  difficulty  in  raising  the  limb,  in  descending 


FRACTURES  OF  THE  KNEE. 


221 


in  keeping  it  extended;  the  uniting  ligament  is  liable 
to  be  torn,  and  the  other  patella  to  be  broken  by 
falls  ;  therefore  the  surgeon  should  bring  the  bones 
as  near  together  as  he  can,  to  render  the  ligamentous 
union  as  short  as  possible,  and  consequently  to  leave 
the  muscle  with  as  much  of  its  original  power  as  the 
nature  of  the  accident  Avill  permit.* 


THE  PERPENDICULAR  FRACTURE  OF  THE  PATELLA. 

There  is  in  the  collection  at  St  Thomas's  Hospital 
a  patella,  one-fourth  of  which  has  been  broken  off; 
the  edge  is  smooth,  and  no  attempt  at  ossific  union 
appears  to  have  been  made. 

Ligamentous  union.  —  A  gentleman  consulted  me 
who  had  about  one-third  of  the  patella  separated 
from  the  other  part  of  the  bone ;  it  had  united  by 
ligament,  for  there  was  free  motion  between  the 
fractured  piece  of  bone. and  that  from  which  it  had 
been  removed.  He  recovered  quickly  from  this 
injury,  and  it  affected  his  power  of  walking  very 
little. 

During  the  winter  of  1822,  a  body  was  dissected 

*  From  the  few,  though  well  attested  instances  in  which  frac- 
ture of  the  patella  has  been  followed  by  bony  union  we  cannot 
doubt  but  that  bone  would  be  produced  in  every  instance  if  it 
were  possible  to  keep  the  fractured  pieces  accurately  in  apposi- 
tion. It  has  been  frequently  suggested  that  the  patella  and  cranium 
are  never  consolidated  by  bone  when  the  one  has  been  broken 
or  a  portion  of  the  other  removed;  lest  the  irregularity  of  the 
callus  should  destroy  the  functions  of  the  subjacent  parts.  But 
we  have  now  on  record  instances  of  the  reproduction  of  bone  in 
both  the  cases  mentioned,  and  must  believe  that  the  distance  of 
the  surfaces  from  each  other  is  the  cause  of  the  want  of  bony 
union.  .T.  D.  G. 


222 


FRACTURES  OF  THE  KNEE. 


at  St  Thomas's  Hospital,  in  which  both  the  patellas 
had  been  broken  longitudinally,  and  although  they 
were  in  contact,  they  were  both  united  by  ligament. 
Mr  Silvester,  one  of  our  pupils,  had  the  kindness  to 
make  a  drawing  of  one  of  these,  of  which  I  have 
given  a  plate. 

This  circumstance  surprised  me,  because  I  saw  no 
reason  why  the  patella  should  not  be  united  by  bone 
when  broken  perpendicularly,  as  I  thought  the  mus- 
cles would  have  a  tendency  to  bring  the  parts  to- 
gether. I  made  it  therefore  a  subject  of  experi- 
ment. 

Experiment  L 
Union  by  ligament  in  experiments. —  July  31st,  1818, 
I  broke  the  patella  of  a  dog  by  placing  a  knife  upon 
it  in  the  longitudinal  direction,  having  first  drawn  the 
integuments  aside;  and  on  the  12th  of  September 
following  I  examined  the  part,  when  I  found  the 
two  portions  of  bone  considerably  separated  from 
each  other,  and  united  by  ligament.  The  cause  was 
as  follows  :  When  I  had  di\^ided  the  bone,  the  knee 
became  bent,  the  condyles  of  the  os  femoris  pressed 
against  the  inner  side  of  the  patella,  and  thrust  the 
parts  asunder,  and  only  a  ligamentous  union  took 
place.    (aScc  Plate.) 

Experiment  11. 
August  2nd,  1818,  I  broke  in  the  same  manner 
the  patella  of  a  rabbit,  and  examined  the  parts  on 
September  3rd,  when  I  found  the  two  portions  of 
bone  widely  separated,  and  united  only  by  ligament- 
ous matter.  I  now  began  to  think  it  impossible  for 
the  patella  to  unite  by  bone,  but  determined  to  make 
another  experiment  to  determine  this  point. 


FRACTURES  OF  THE  KNEE. 


223 


Experiment  III. 
Union  by  hone, — I  divided  the  patella  longitudi- 
nally in  a  dog,  but  took  care  that  the  division  should 
not  extend  into  the  tendon  above  or  to  the  ligament 
below  it,  so  that  there  should  be  no  separation  of 
the  two  portions.  I  examined  it  three  weeks  after, 
and  found  it  united  ;  no  separation  existing  between 
the  two  portions.*    (^See  Plate.) 

Experiment  IV. 
October,  1819.  I  divided  the  patella  by  a  crucial 
fracture  into  four  portions;  the  two  upper  portions 
neither  united  with  each  other  nor  with  the  bones 
below,  but  the  two  lower  portions  became  united  by 
bone.t 

It  appears  then  that  under  longitudinal  and  trans- 
verse fracture,  a  ligamentous  union  is  generally  pro- 
duced, and  that  it  arises  from  the  separation  produc- 
ed in  the  bone;  but  that  if  that  cannot  separate, 
and  its  parts  remain  in  contact,  ossific  union  may  be 
produced.  In  the  summer  of  1819,  Mr  Marryat 
was  thrown  from  his  gig  as  he  was  passing  along  the 
Strand ;  by  the  fall  he  fractured  his  patella  trans- 
versely, and  the  lower  portion  of  the  bone  was  also 
broken  perpendicularly,  so  that  it  was  divided  into 

*  The  bone  was,  under  maceration,  found  united  in  part  by 
bone,  and  in  part  by  cartilage,  not  yet  completely  ossified.  It 
is  preserved,  and  may  be  seen  at  any  time  by  tl^ose  who  are 
curious  to  examine  it. —  A.  C. 

t  All  these  experiments  tend  to  prove  the  correctness  of 
what  has  been  heretofore  advanced,  relative  to  the  absence  of 
bony  union.  In  all  the  instances  where  bony  union  did  not  oc- 
cur, we  see  that  the  fragments  were  liable  to  separation  from 
the  motions  of  the  Umb.  J.  D.  G. 


224 


FRACTURES  OF  THE  KNEE. 


three  pieces.  The  transverse  fracture  united,  as 
usual,  by  ligament  ;  but  the  perpendicular  by  bone. 

Mr  Parrott,  of  Tooting,  who  also  attended  the 
case,  writes  in  these  words: 

'Dear  Sir,  —  I  have  great  pleasure  in  replying  to 
your  letter.  The  longitudinal  fracture  of  the  patel- 
la of  Mr  M.  has  become  very  firmly  consolidated, 
but  there  is  a  line  or  ridge  to  be  traced  upon  the 
surface  of  the  bone,  which  marks  distinctly  the  place 
where  it  had  been  separated.' 

Treatment,  —  In  the  longitudinal  or  perpendicular 
fracture  of  the  patella,  the  best  treatment  consists 
in  extending  the  leg,  and  in  using  local  depletion  and 
evaporating  lotions ;  in  a  few  days  a  roller  should 
be  applied  around  the  limb,  and  then  a  laced  knee- 
cap, with  a  strap  to  buckle  around  the  knee  above 
and  below  the  patella,  and  a  pad  on  each  side  to 
bring  its  parts  as  nearly  as  possible  into  contact. 


COMPOUND  FRACTURE  OF  THE  PATELLA. 

From  violence  or  ulceration.  —  These  fractures  oc- 
cur from  injury,  or  from  an  ulcerative  process  under 
peculiar  circumstances. 

The  cases  which  I  have  seen  of  this  accident  are 
as  follow : 

Case,  —  A  man  was  admitted  into  Guy's  Hospital, 
in  the  year  1796,  under  Mr  Wc  Cooper,  surgeon  of 
that  hospital,  with  a  compound  fracture  of  this 
bone;  violent  inflammation  followed;  suppuration 
ensued,  with  the  highest  degree  of  constitutional 
irritation ;  and  as  no  opportunity  was  given  for  am- 
putation, from  the  great  swelling  of  the  thigh,  this 
man  died.    The  bone  is  in  the  Museum  of  St  The- 


FRACTURES  OF  THE  KNEE. 


225 


mas's  Hospital,  disunited  as  at  the  first  moment  of 
the  accident. 

Case,  —  A  man  was  admitted  into  St  Thomas\s 
Hospital,  under  the  care  of  Mr  Birch,  with  a  frac- 
ture of  the  patella,  and  a  small  wound  extending  in- 
to the  joint.  The  knee  was  fomented  and  poultic- 
ed ;  inflammation  and  suppuration  followed ;  and 
this  man  in  a  few  dajs  died  with  the  highest  symp- 
toms of  constitutional  irritation. 

Case.  —  Mr  Hawker,  surgeon,  called  me  to  visit 
a  man  who  had  just  arrived  in  Lpndon  ;  and  who, 
being  at  Avork  in  a  warehouse  up  one  pair  of  stairs, 
on  hearing  the  signal  for  dinner,  seeing  the  doors 
of  the  warehouse  open,  walked  quickly  out,  and  fell 
into  the  street.  By  this  fall  he  had  a  compound 
fracture  of  the  patella.  The  limb  was  attempted 
to  be  saved.  The  joint  suppurated;  the  discharge 
became  excessively  great ;  and  the  symptoms  of  ir- 
ritation ran  so  high,  that  I  thought  he  would  not 
recover;  but  he  became  somewhat  better,  and  I 
advised  him  to  go  into  the  country.  I  afterwards 
heard  that  he  gradually  recovered  with  an  anchy- 
losed  joint. 

Case,  —  Mr  Redhead,  residing  at  Kennington 
Cross,  aged  thirty-nine  years,  was  thrown  from  his 
gig,  on  June  18th,  18] 9,  against  a  cart-wheel.  His 
knee  came  violently  in  contact  with  the  wheel,  which 
fractured  his  patella  and  opened  the  joint.  Mr 
Dixon,  of  Newington  Butts,  was  sent  for,  and  he 
found  that  the  knee  had  bled  freely  from  a  wound 
on  its  outer  side,  from  which  the  synovia. freely  es- 
caped, and  which  readily  admitted  his  finger  to  the 
shattered  patella.  The  accident  happened  at  ten 
o'clock  in  the  morning ;  I  was  sent  for  by  Mr  Dix- 
on, and  when  1  met  him  at  four  o'clock,  I  found  a 
wound  on  the  fore  part  of  the  knee,  through  which 
I  readily  passed  my  finger  into  the  joint.  The 
29 


226 


FRACTURES  OF  THE  KNEE. 


patella  was  not  broken  transversely,  but,  as  I  have 
expressed  it,  shattered ;  that  is,  broken  into  several 
pieces  ;  and  a  small  piece  which  was  separated  from 
the  rest  I  removed.    It  was  agreed  between  Mr 
Dixon  and  myself,  that  an  attempt  should  be  made 
to  save  the  limb,  for  the  patient  was  of  a  spare 
habit,  and,  by  his  great  composure,  showed  that  he 
was  not  of  an  irritable  constitution.    I  passed  a  su- 
ture through  the  integuments,  knowing  the  difficulty 
of  keeping  the  wound  closed  on  account  of  the  con- 
tinued escape  of  synovia,  but  taking  the  utmost  care 
that  the  ligament  should  not  be  included  in  the 
suture.    Adhesive  plaster  was  also  applied  over  the 
wound,  and  rollers  lightly  put  on,  which  were  kept 
constantly  wet  with  spirits  of  wine  and  water.  The 
leg  was  placed  in  the  extended  position,  and  he  was 
ordered  not  to  move  it  in  the  slightest  degree,  and 
to  live  on  fruit. 

Saturday.  He  had  passed  a  very  good  night,  and 
was  free  from  pain  or  fever. 

Sunday  night.  He  was  restless,  and  was  thought 
delirious. 

Monday  morning.  He  had  a  dose  of  ol.  ricini, 
which  relieved  him  from  his  feverish  feelings. 

Tuesday.  He  stated  he  had  passed  a  good  night, 
and  he  afterwards  had  no  bad  symptoms.  As  there 
was  no  swelling,  no  inflammation,  and  scarcely  any 
pain,  the  suture  was  not  removed  until  the  30th  of 
June,  when  the  adhesive  plaster  was  renewed. 

He  recovered  without  any  untoward  accident. 
Mr  Dixon  ordered  him  from  bed  in  a  month,  and  at 
the  end  of  five  weeks  gave  the  joint  slight  passive 
motion.  On  the  7th  of  August,  the  patient  walked 
across  his  room ;  and  he  entirely  recovered  the  use 
of  his  limb. 


If  the  laceration  be  extensive,  or  the  contusion 


FRACTURES  OF  THE  KNEE. 


227 


very  considerable  in  these  cases,  amputation  will  be 
required;  but  if  the  wound  be  small, and  the  patient 
be  not  irritable,  and  no  sloughing  of  the  integuments 
or  ligament  be  likely  to  occur  from  the  nature  of 
the  accident,  it  will  be  best  to  try  to  save  the  limb; 
and  the  treatment  of  Mr  Redhead's  case  is  that 
which  1  should  pursue.  The  principal  object  is  to 
produce  adhesion  immediately ;  and  every  means  in 
our  power  must  be  used  for  that  purpose.  I  know 
well  that  sutures  are  generally  objectionable,  and  I 
never  employ  them  if  1  can  possibly  succeed  without 
them ;  but  in  moveable  parts,  in  those  w^hich  are 
unsupported,  and  in  those  through  which  a  secretion 
is  liable  to  force  its  way,  they  are  not  only  justifiable, 
but  highly  necessary.  Fomentations  and  poultices 
must  not  be  employed  in  these  cases,  as  they  prevent 
the  adhesive  process. 

A  compound  fracture  of  the  patella  will  be  some- 
times produced  by  an  ulcer,  as  in  the  following 
case. 

Ulceration. — A  w^oman  was  admitted  into  Guy's 
Hospital  in  1816,  with  a  simple  and  transverse  frac- 
ture of  the  patella,  which  had  long  been  united  by 
a  ligament  of  about  three  inches  in  extent.  Ulcers 
were  formed  upon  different  parts  of  the  body;  and, 
unfortunately,  one  of  these  upon  the  integuments 
over  the  ligamental  union  of  the  patella.  It  became 
sloughy,  and  extended  through  the  new  ligament  to 
the  joint,  which  it  laid  open  :  violent  constitutional 
irritation  succeeded;  a  copious  suppuration  was  pro- 
duced; and  no  opportunity  was  given  of  amputating 
the  limb,  for  the  inflamed  and  swollen  state  of  the 
thigh  forbade  it.    This  woman  died. 


228 


FRACTURES  OF  THE  KNJGE. 


OBLiqUE  FRACTURES  OF  THE  CONDYLES  OF  THE  OS 
FEMORIS   INTO  THE  JOINT. 

Of  either  condyle.  —  These  cases  are  of  rare  occur- 
rence ;  but  when  thej  happen  it  is  difficult  to  pre- 
vent deformity,  and  to  restore  to  the  patient  a  sound 
and  useful  limb.  Thej  are  known  by  the  great 
swelh'ng  of  the  joint  which  ensues,  by  the  crepitus 
which  is  felt  in  moving  the  joint,  and  by  the  deform- 
ity consequent  upon  them.  The  fracture  is  some- 
times of  the  inner,  and  sometimes  of  the  outer  con- 
dyle, and  the  bone  is  split  down  into  the  joint. 

Treatment, — Whether  the  external  or  internal  con- 
dyle be'broken,  the  same  treatment  is  required.  The 
limb  is  to  be  placed  upon  a  pillow  in  the  straight 
position,  and  evaporating  lotions  and  leeches  are  to 
be  used  to  subdue  the  swelling  and  inflammation. 
When  this  object  has  been  effected,  a  roller  is  to  be 
applied  around  the  knee,  and  a  piece  of  stiff  paste- 
board, about  sixteen  inches  long  and  sufficiently  wide 
to  extend  entirely  under  the  joint,  and  to  pass  on 
each  side  of  it,  so  as  to  reach  to  the  edge  of  the 
patella,  is  to  be  dipped  in  warm  water,  applied  under 
the  knee,  and  confined  by  a  roller.  When  this  is 
dry,  it  will  have  exactly  adapted  itself  to  the  form 
of  the  joint,  and  this  form  it  will  afterwards  retain, 
so  as  best  to  confine  the  bones.  Splints  of  wood  or 
tin  may  be  used  on  each  side  of  the  joint,  but  they 
are  apt  to  cause  uneasy  pressure.  In  five  weeks 
passive  motion  of  the  limb  may  be  gently  begun,  to 
prevent  anchylosis.  I  prefer  the  straight  position  in 
these  cases,  because  the  tibia  presses  the  extremity 
of  the  broken  condyle  into  a  line  with  that  which  is 
not  injured. 

Compoundfracture,  —  Examples  of  compound  frac- 


FRACTURES   OP  THE  KNEE. 


229 


tures  of  the  condyles  are  very  unfrequent :  the  fol- 
lowing was  under  the  care  of  Mr  Travers,  in  St 
Thomas's  Hospital,  who  was  so  kind  as  to  send  me 
.  the  history  of  it. 

Case, —  Michael  Dixon  was  admitted  into  St 
Thomas's  Hospital,  September  17th,  1816,  for  a 
fracture  of  the  lower  extremity  of  the  femur,  caus- 
ed by  a  carriage  wheel  in  motion,  with  which  his 
legs  became  entangled.  There  was  much  displace- 
ment of  the  fractured  bone,  and  a  small  wound  op- 
posite the  external  condyle.  Upon  examination  it 
was  evident  that  the  fracture  had  extended  nearly 
in  the  direction  of  the  axis  of  the  bone,  and  there 
was  a  transverse  fracture  of  the  shaft  of  tlie  bone 
above  the  joint ;  the  external  condyle  was  move- 
able, and  thrown  out  of  its  place  during  the  accident, 
as  if.  it  had  been  drawn  by  the  leg,  which  was  twist- 
ed inwards.  The  iimb  was  laid  in  a  fracture  box, 
in  a  semi-flexed  position  on  the  heel ;  the  constitu- 
tional disturbance  w^as  very  slight. 

Oct.  5.  The  external  condyle  is  still  moveable  : 
the  integuments  over  it  are  ulcerated,  so  as  to  de- 
nude the  bone.    The  health  remains  good. 

Nov.  5.  The  broken  bone  protrudes  and  appears 
to  be  dead ;  it  is  surrounded  by  fungous  granula- 
tions, and  there  is  but  little  discharge. 

Nov.  18.  The  protruded  bone  having  been  gent- 
ly twisted  off  by  forceps,  proved  to  be  the  external 
condyle,  with  its  articular  surface  :  there  still  pro- 
truded a  small  portion  of  bone,  but  this  soon  healed 
over.  The  limb  was  now  placed  in  an  extended 
position,  as  anchylosis  was  considered  unavoidable. 

Dec.  1.  The  boy  has  recovered  almost  the  per- 
fect use  of  his  limb,  and  is  enabled  to  bend  and  ex- 
tend it  without  pain. 

Dec.  6.    The  boy  was  discharged  from  the  hos- 


0 


230  FRACTURES  OF  THE  KNEE. 

pital.    The  wound  was  healed,  and  he  can  walk 
tolerably  well  with  a  stick. 

On  the  February  following  he  called  at  the  hos- 
pital, walking  without  any  support,  and  having  free  • 
use  of  the  joint.*  - 

To  aged  persons  these  accidents  sometinaes  prove 
fatal,  as  in  the  following  example;  and,  indeed,  1 
have  known  a  simple  fracture  of  the  condyles  pro- 
duce the  same  effect. 


COMPgUND  FRACTURE  OF  THE  CONDYLES   OF  THE 
FEMUR. 

Vases  of  compound  fracture  of  condyles.  —  Bluk- 
wick,  aged  seventy-six,  on  the  1st  of  January,  1822, 
slipped  accidentally  olF  the  curb-stone,  and  received 
the  whole  weight  of  the  body  upon  the  knee.  The 
patella  appears  to  have  acted  as  a  wedge  between 
the  two  condyles  of  the  os  femoris,  which  were 
separated  by  a  fracture,  running  obliquely  along  the 
shaft  of  the  bone,  the  end  of  which  was  forced 
through  a  wound  in  the  integuments.  The  patella 
remained  in  its  place,  and  was  unbroken.  The  pa- 
tient at  the  time  of  the  accident  was  in  a  state  of 
inebriety.    MrRowe,  of  Burton  Crescent,  to  whom 

*  A  case  of  fracture  of  the  external  condyle,  complicated 
with  an  extensive  cut  into  the  joint,  occurred  in  the  practice 
of  a  surgeon  of  my  acquaintance.  The  wound  was  produced 
by  a  violent  stroke  with  an  axe,  which  entered  the  joint  at  the 
outer  edge  of  the  patella,  and  sticking  into  the  femur  split  the 
external  condyle  obliquely  from  the  shaft  of  the  bone.  The 
accident  happened  in  very  cold  weather;  the  edges  of  the 
wound  were  stitched,  and  contrary  to  all  expectation  the  patient 
entirely  recovered,  without  any  loss  of  bone,  under  the  careful 
employment  of  the  antiphlogistic  regimen.  J.  D.  G. 


FRACTURES  OF  THE  KNEE.  23  I 

1  am  indebted  for  the  particulars  of  the  case,  saw 
him  about  three  hours  after  the  accident :  he  had 
him  conveyed  to  bed,  and  without  much  difficulty 
brought  the  fractured  bones  in  apposition ;  they 
were  retained  in  their  situation  by  splints  and  ban- 
dages, and  the  limb  was  placed  in  the  straight  posi- 
tion. A  lotion  of  the  liquor  plumBi  was  applied 
over  the  part,  and  an  opiate  was  administered  at 
night. 

The  patient  passed  a  tolerable  quiet  night,  and  in 
the  morning  was  pretty  free  from  pain.  An  aperient 
draught  was  administered,  which  operated  freely. 
On  the  evening  of  this  day  I  was  called  in  to  him. 
I  directed  a  leathern  cap  to  be  strapped  over  the 
fractured  part,  and  the  straight  position  of  the  limb 
to  be  preserved.  The  patient  was  ordered  a  regu- 
lar diet,  and  saline  draughts,  with  an  occasional 
opiate. 

This  treatment  was  continued  until  the  twenty- 
first  day  from  the  accident,  and  the  patient  remained 
free  from  any  bad  symptom.  On  the  evening  of 
that  day,  however,  he  was  found  much  heated,  with 
a  very  frequent  pulse,  dry  tongue,  and  a  tendency  to 
delirium  :  these  alarming  symptoms,  it  appears,  were 
increased  by  a  glass  of  brandy  and  water  taken  con- 
trary to  the  direction  of  his  medical  attendant.  Mr 
Rowe  ordered  him  an  aperient,  but  the  danger  was 
rapidly  increasing  :  the  patient  was  found  next  morn- 
ing in  a  high  degree  of  fever;  pulse  one  hundred 
and  thirty;  countenance  exhibiting  great  depression. 
These  unfavourable  symptoms  went  on  increasing, 
and  on  the  twenty-fourth  he  died. 

The  limb,  on  examination  after  death,  exhibited 
great  signs  of  inflammation  ;  a  considerable  quantity 
of  matter  was  found  between  the  muscles  of  the 
thigh,  part  of  which  was  discharged  by  the  external 
wound. 


232 


FRACTURES  OF  THE  KNEE. 


Dissection. 

On  examining  the  thigh-bone  its  shaft  was  found 
broken  very  obliquely,  about  seven  inches  above  the 
knee-joint ;  and  the  bone  was  split  down  into  the 
joint,  near  to  the  centre,  between  the  condyles,  but 
inclining  somewhat  to  the  external  condyle :  this 
portion  of  the  bone  was  loose  and  detached  from 
the  internal  condyle :  there  was  also  a  piece  three 
inches  in  extent,  detached  from  the  shaft  of  the  bone, 
which  however  had  fallen  into  the  cancelli,  where  it 
remained  lodged.    {See  Plate.) 


OBLiqUE  FRACTURES  OF  THE  OS  FEMORIS  JUST  ABOVE 
ITS  CONDYLES. 

Oblique  fractures  of  the  condyles.  —  This  is  a  most 
formidable  injury  from  its  consequences  on  the  future 
form  and  use  of  the  limb  ;  for  it  is  liable  to  termi- 
nate most  unfortunately,  by  producing  deformity, 
and  by  preventing  the  flexion  of  the  knee-joint. 

It  is  only  of  late  years  that  I  have  had  an  oppor- 
tunity of  investigating  this  case  by  dissection  ;  and, 
consequently,  of  obtaining  substantial  knowledge  of 
the  exact  nature  of  the  injury.  The  appearances 
produced  by  it  are,  that  the  lower  and  broken  ex- 
tremity of  the  shaft  of  the  bone  projects,  and  forms 
a  sharp  point  just  above  the  patella,  which  pierces 
the  rectus  muscle,  threatens  to  tear  the  skin,  and 
sometimes  does  tear  it :  whilst  the  patella,  tibia,  and 
condyles  of  the  os  femoris  sink  into  the  ham,  and 
are  drawn  upwards  behind  the  broken  extremity  of 
the  shaft  of  the  os  femoris. 

The  accident  happens  when  a  person  falls  from  a 
considerable  height  upon  his  feet,  or  is  thrown  upon 


FRACTURES   OF  THE  KNEE. 


233 


the  condyles  of  the  os  femorls  with  the  knee  bent. 
In  all  the  cases,  the  fracture  was  very  oblique 
through  the  shaft  of  the  bone;  and  hence  the  point- 
ed appearance  of  the  cxticmity  of  the  fracture,  and 
tlie  difficulty  of  keeping  the  bones  in  apposition. 

Case.  —  A  body  was  brought  into  the  dissecting- 
room  at  St  Thomas's  Hospital,  which  fell  to  the  lot 
of  Mr  Patey,  surgeon,  of  Dorset-street,  Portman- 
square,  to  dissect,  and  he  kindly  permitted  me  to 
make  a  drawing  from  the  limb.  It  appeared,  upon 
view  of  the  thigh,  that  the  limb  had  been  broken 
just  above  the  knee-joint,  and  that  the  shaft  of  the 
bone  projected  as  far  as  the  skin,  just  above  the  pa- 
tella :  the  union  was  firm,  but  the  magnitude  of  the 
bone  was  exceedingly  increased.  When  the  integu- 
ments were  removed,  the  end  of  the  superior  portion 
of  the  shaft  of  the  bone  was  found  to  have  pierced 
the  rectus  muscle,  through  which  it  still  continued 
to  project  (See  Plate);  and  behind  this  projecting  por- 
tion of  bone  the  rectus  muscle  was  situated,  which 
passed  to  the  patella.  The  patella,  on  the  attempt 
to  draw  it  up,  was  stopped  by  the  projection  of  the 
fracture,  so  that  its  movement  upwards  was  exceed- 
ingly limited.  The  condyles  of  the  os  femoris,  and 
the  lower  portion  of  the  bone,  had  been  drawn  by 
the  action  of  the  muscles  behind  the  end  of  the 
fracture  of  the  upper  portion,  and  had  united  by  a 
very  firm  callus  to  the  body  of  the  bone. 

This  union  had  necessarily  produced  a  great  dimi- 
nution in  the  power  of  extending  the  limb;  for  the 
rectus  muscle  was  really  hooked  down  by  the  frac- 
tured extremity  of  the  bone  :  but  even  if  the  bone 
had  not  piei'ced  the  muscle,  still  the  elevation  of  the 
patella  would  have  been  prevented,  by  that  bone 
being  drawn  against  the  fractured  end  of  the  thigh- 
bone in  the  contraction  of  the  muscle.  It  appears, 
then,  that  in  the  treatment  of  this  case,  a  most  firm 
30 


234 


FRACTURES   OF  THE  KNEE. 


and  continued  extension  must  be  supported  lo  pre- 
vent the  retraction  which  will  otherwise  ensue  ;  but 
it  will  be  seen  by  the  two  following  cases,  that  this 
defective  union  is  with  great  difficulty  prevented ; 
and  that  the  complete  flexion  of  the  limb  afterwards, 
was  not  in  either  instance  accomplished. 


COMPOUND  FRACTURE  JUST  ABOVE  THE  CONDYLES  OF 
THE   OS  FEMORIS. 

Case. —  Mr  Kidd,  who  weighed  fifteen  stone,  fell, 
on  the  9th  of  November,  1819,  from  the  height  of 
twenty-one  feet  upon  his  feet,  and  broke  his  thigh- 
bone just  above  the  knee  by  the  severity  of  the 
concussion.  The  fracture  was  situated  immediately 
above  the  condyles,  and  the  broken  extremity  of 
the  shaft  of  the  bone  appeared  through  the  integu- 
ments and  rectus  muscle,  just  above  the  patella.  He 
was  immediately  carried  home,  and  I  saw  him,  with 
Mr  Phillips,  surgeon  to  the  King's  household,  a  short 
time  after  the  accident.  We  agreed  that  the  pro- 
jecting extremity  of  the  thigh-bone  should  be  imme- 
diately sawn  off,  and  that  the  edges  of  the  wound 
should  be  approximated  so  as  to  render  the  fracture 
simple  ;  and  this  was  immediately  done.  The  limb 
was  placed  upon  the  double  inclined  plane.  The 
wound  healed  without  difficulty,  and  our  first  object 
was  thus  accomplished.  On  the  30th  of  November, 
splints  were  applied,  in  order  to  press  the  bones 
firmly  together.  On  December  23rd,  the  leg  was 
straightened,  and  the  inclined  plane  was  lowered,  so 
as  to  bring  the  limb  gradually  into  a  straight  position. 
On  February  the  2nd,  he  sat  up  in  bed.  On  the 
7th  of  February,  the  knee  having  been  moved,  the 
fractured  bones  appeared  to  separate,  and  on  the 


FRACTURES  OF  THE  KNEE. 


235 


14th  it  was  clearly  ascertained  that  the  bone  was 
not  united.  On  the  16th,  a  leathern  bandage  with 
many  straps  was  tightly  buckled  around  the  knee. 
Having  previously  tried  the  position  upon  his  side, 
which  only  led  to  a  greater  separation  of  the  bone, 
he  was  again  placed  upon  his  back.  On  the  3d  of 
May,  the  bone  was  found  to  be  united,  and  on  the 
r2th,  the  leathern  bandage  was  removed,  and  the 
limb  placed  on  a  pillow.  On  the  10th  of  July, 
he  moved  from  one  side  of  the  bed  to  the  other 
with  difficulty,  and  on  the  16th,  was  placed  on  an- 
other bed,  which  was  obliged  to  be  adjusted  to  the 
exact  level  with  the  former,  before  his  removal 
could  be  accomplished.  On  July  the  19th,  he  w^as 
removed  from  London  to  Kensington  on  a  litter. 
On  the  8th  of  August,  the  thigh  was  fomented,  in 
order  to  remove  the  excessive  bulk  it  had  acquired, 
and  to  diminish  its  hardness  ;  1  ut  the  fomentation 
was  discontinued  on  the  14th,  because  it  was  found  to 
increase  the  swelling.  On  the  15th,  the  leg  was 
bathed  with  the  liquor  plumbi  subacetatis  dilutus, 
and  spirits  of  wine  :  the  skin  having  been  ulcerated 
from  the  time  that  the  bandage  was  buckled  tight 
around  the  knee.  On  October  the  24th,  the  leg 
was  placed  in  a  gout  cradle.  On  the  26th,  he  was 
on  a  sofa  for  two  hours,  but  on  the  28th5  was  obliged 
to  keep  in  bed,  because  irritation  and  swelling  had 
been  produced  by  moving  on  the  two  preceding 
days.  On  November  the  3rd,  he  was  wheeled  into 
another  room  on  a  chair.  On  January  the  29th, 
1822,  he  was,  for  the  first  time,  on  crutches;  and  on 
February  the  24fch,  he  first  walked  out  of  doors. 

His  present  state,  March  1822,  is  as  follows:  The 
bone  above  the  knee  is  excessively  enlarged;  the 
patella  is  fixed  below  the  broken  ex.tremity  of  the 
shaft  of  the  bone,  the  point  of  which  adheres  to  the 
skin. 


236 


FRACTURES   OF  THE  KNEE. 


Mr  Kidd  possessed  a  very  fine  constitution,  for 
his  puise  after  the  accident  never  exceeded  63  ;  and 
although  the  rectus  muscle  was  penetrated  by  tlie 
bone,  he  never  complained  of  any  spasmodic  con- 
traction of  the  limb. 


SIMPLE  FRACTURE  ABOVE  THE  CONDYLES  OF  THE  OS 
FEMORIS. 

For  the  following  history  1  am  indebted  to  Mr 
Welbank,  Jun.,  who  attended  the  case  with  me. 

Case,  —  Mr  — ,  of  middle  age,  muscular  and  tall, 

v^^as  driving  on  the  morning  of  July  20th,  1821,  in  the 
neighbourhood  of  Leicester-fields,  and  was  thrown 
forward  out  of  his  gig,  over  the  horse,  which  had 
fallen.  It  is  probable  that  the  external  condyle  of 
the  right  femur  received  the  force  and  w-eight  of 
his  descent  upon  the  pavement.  He  was  brought 
from  Leicester-fields  to  Chancery-lane  in  a  coach, 
with  his  legs  out  of  the  door,  no  surgical  assistance 
having  been  yet  procured.  When  first  seen  by  his 
surgical  attendant  he  was  lying  upon  his  back  on  the 
bed,  with  the  right  leg  bent  and  lying  across  the 
middle  of  the  left  leg  at  an  angle.  There  was  an 
appearance  resembling  the  lateral  dislocation  of  the 
knee,  from  a  deep  hollow,  visible  on  the  external 
side  of  the  joint,  in  the  situation  of  the  external 
condyles  ;  above  this  hollow  close  to  the  joint,  and 
on  its  external  or  fibular  side,  an  abrupt  and  sharp 
projection  of  bone  was  distinctly  observable.  Slight 
extension  replaced  the  parts,  and  it  now  appeared 
that  the  thigh  had,  previously  to  the  reduction, 
been  bent  inwards  over  the  left,  upon  an  oblicjue 
fracture,  situated  close  to  the  patella.  The  patella 
itself  was  very  obscurely  felt  through  a  circumscribed 


FRACTURES   OF  THE  KNEE. 


237 


effusion  in  front  of  the  joint.  Just  above  the  situ- 
ation of  its  upper  edge  might  still  be  traced  the  ridge 
of  the  fracture,  a  sliglit  groove  intervening:  the  ap- 
pearance, indeed,  at  this  and  later  periods  of  the 
accident  might  have  been  mistaken,  on  superficial 
examination,  for  the  transverse  fracture  of  the  pa- 
tella. Flexion  produced  great  projection  of  the 
upper  part  of  the  femur,  and  extension  readilj  re- 
stored the  natural  appearance,  except  in  the  swelling 
on  the  front  of  the  patella.  The  crepitus  was  verj 
indistinct,  if  at  all  observable. 

Little  more  was  done  during  the  first  week  than 
steadying  the  joint  in  the  extended  position  with 
short  splints,  and  subduing  the  inflammation  of  the 
capsule  which  supervened.  After  this  period,  a  long 
splint  was  applied  from  the  trochanter  major  to  the 
outside  of  the  foot,  and  an  opposing  short  splint  from 
the  middle  of  the  femur  to  the  middle  of  the  inside 
of  the  leg,  and  firmly  confined  by  tapes  and  buckles. 
The  whole  limb  was  supported  upon  an  inclined 
plane,  and  flexion  cautiously  obviated.  To  prevent 
motion  of  the  pelvis  the  stools  were  removed  in 
napkins.  The  posture  was  not,  however,  steadily 
maintained;  and  it  was  frequently  found  that  the 
upper  point  of  bone  varied  in  its  degrees  of  projec- 
tion, and  at  different  times,  more  or  less,  encroached 
on  the  situation  of  the  upper  edge  of  the  patella. 
To  remedy  this,  slight  permanent  extension,  with 
weights  appended  to  the  foot,  was  adopted  with 
advantage  ;  though  1  believe  that  the  position  was 
by  no  means  rigorously  maintained,  for  I  have  since 
understood  that  the  patient,  not  unfrequently,  even 
had  his  back  washed.  The  ridge  of  the  upper  por- 
tion of  the  femur  appeared,  however,  to  project  so 
slightly,  that  it  was  deemed  better  to  ensure  union, 
than  to  add  to  the  frequency  of  disturbance,  by  beii  g 
too  solicitous  of  exact  apposition. 


238 


FRACTURES   OF   THE  KNEE. 


About  September  the  7th,  the  bone  was  thought 
sufficiently  united,  but  flexion  was  neither  attempted 
by  the  surgeon,  nor  permitted  to  the  patient.  On 
September  the  10th,  the  patient  was  removed  to 
Eastbury,  Hertfordshire,  in  a  litter-carriage,  as  his 
health  was  suffering:  the  limb  being  steadied  with 
splints,  and  the  position  resumed,  during  the  journey. 
In  removing  from  one  bed  to  another,  and  in  other 
alterations  of  posture,  it  was  obvious  that  flexion 
produced  a  greater  appearance  of  projection  of  the 
femur  than  had  been  anticipated.  This  might  be 
referred  to  the  drawing  down,  or  rather  sinking  of 
the  patella  in  flexion ;  and,  indeed,  it  could  to  ap- 
pearance be  nearly  remedied  by  elevating  the  leg 
upon  the  thigh,  as  in  extension.  Under  these  cir- 
cumstances, however,  rest  in  the  extended  posture 
was  again  adopted  for  a  fortnight.  About  Septem- 
ber 2r)th,  a  second  examination  decided  the  necessity 
for  further  rest,  as  the  increase  of  projection,  on 
flexion  of  the  knee,  and  a  slight  lateral  motion,  in- 
duced a  belief  of  infirm  union.  It  is  worthy  of 
mention,  that  the  immediate  vicinity  of  the  joint,  the 
mobility  of  the  patella,  and  the  general  thickening, 
rendered  all  examinations  of  extreme  difficulty  and 
uncertainty.  A  circular  belt  was  tightly  girded  upon 
the  situation  of  the  injury,  with  a  view  of  compress- 
ing the  fracture,  and  maintaining  the  parts  in  .  firm 
apposition.  On  October  16th,  the  union  was  con- 
sidered complete,  and  the  patient  was  allowed  to 
get  up.  On  November  1st,  he  resumed  his  pro- 
fessional duties  as  an  advocate.  For  a  considerable 
period  he  suffered  pain  and  swelling  of  the  limb,  but 
has  gradually  and  slowly  improved. 

May,  1822.  At  this  date  he  can  walk  about  his 
room  without  assistance  either  of  crutch  or  stick. 
He  has  little  power  of  flexion  at  the  knee-joint. 
The  joint  is,  however,  apparently  moveable  to  a 


FKACTURES    OF   THE  KNEE. 


239 


certain  extent  beneath  the  pateUa,  which  bone  is 
fixed  beneath  the  projecting  edge  of  the  upper  por- 
tion of  the  femur,  which  evidently  overlaps  and  dis- 
places it.  There  is  visible  shortening  of  the  limb, 
and  the  contour  of  the  thigh  is  somewhat  bowed  out- 
wards. 

J.  Welbank,  Jun. 

Chancery  Lane, 

To  obviate  the  evils  which  are  produced  by  this 
formidable  accident,  I  have  had  an  apparatus  construct- 
ed to  preserve  the  thigh  in  a  constant  state  of  extension. 
(^See  Plate,)  The  leg  is  to  be  first  bent,  to  draw 
the  rectus  muscle  over  the  broken  extremity  of  the 
bone,  and  then  the  apparatus  is  to  be  applied,  and 
the  limb  to  be  preserved  constantly  on  the  stretch 
in  the  rectilinear  position. 


FRACTURE   OF  THE  HEAD   OF   THE  TIBIA. 

Oblique  fractures  of  the  tibia  into  the  joint.  —  The 
head  of  the  tibia  is  sometimes  obliquely  broken  ; 
and  if  it  be  fractured  into  the  knee-joint,  the  treat- 
ment which  it  requires  is  similar  to  that  which  is 
necessary  in  the  oblique  fracture  of  the  condyle  of 
the  OS  femoris;  that  is,  first,  to  maintain  the  straight 
position  of  the  limb,  because  the  femur  preserves 
the  proper  adaptation  of  the  fractured  tibia  by  serv- 
ing as  a  splint  to  its  upper  portion,  and  keeping  the 
articular  surfaces  in  apposkion.  Secondly,  a  roller 
to  press  one  part  of  the  broken  surface  against  the 
other.  Thirdly,  a  splint  of  pasteboard  to  assist  in 
the  preservation  of  that  pressure.  And  fourthly, 
early  passive  motion  to  prevent  anchylosis. 


240 


FRACTURES   OF   THE  KNEE. 


Fracture  just  below  the  joint,  —  But  if  the  fracture 
of  the  tibia  be  ol  lique,  jet  not  into  the  joint,  then  it  is 
best  to  place  the  limb  upon  the  double  inclined 
plane  :  for  the  cause  of  deformity  being  the  eleva- 
tion of  the  lower  portion  of  the  tibia,  which  is  drawn 
up  on  the  side  of  the  knee-joint,  as  the  fracture  is  in 
the  inner  or  outer  side  of  the  tibia,  the  weight  of 
the  leg  keeps  the  limb  constantly  extended  as  it  hangs 
over  the  angle  of  the  inclined  plane,  and  thus  the 
bone  is  brought  into  as  accurate  apposition  as  the  na- 
ture of  the  fracture  permits. 


DISLOCATIONS   OF  THE  HEAD  OF  THE  FIBULA. 

Union  with  the  tibia,  — The  fibula  joins  the  tibia, 
three  quarters  of  an  inch  below  the  articulation  of 
the  knee.  Its  head  is  inclosed  in  a  capsular  hgament, 
which  unites  it  to  the  tibia,  to  which  it  is  also  joined 
through  the  greater  part  of  its  length  by  the  inter- 
osseous ligament. 

Produced  by  violence  or  relaxation,  —  This  bone  is 
liable  to  dislocation,  both  from  violence  and  from 
relaxation.  I  have  only  seen  one  case  of  it  from  vi- 
olence, and  in  that  instance  it  was  connected  with 
the  compound  fracture  of  the  tibia. 

 Briggs,  of   whose  dislocation  of  the  tibia  I 

have  given  an  account,  had,  at  the  upper  part  of  the 
other  leg,  a  compound  fracture  of  the  tibia,  and  dis- 
location of  the  head  of  the  fibula.  An  attempt  was 
made  to  save  the  limb,  but  the  constitutional  irrita- 
tion ran  so  high,  that  amputation  was  obliged  to  be 
performed  ;  which  was  done  by  my  colleague,  Mr 
Lucas,  and  the  man  was  restored  to  health. 

Dislocations  of  the  head  of  the  fibula  from  relax- 
ation, are  more  frequent  than  those   which  occur 


FRACTURES  OF  THE  KNEE. 


241 


from  violence  ;  the  head  of  the  bone,  in  these  cases, 
is  thrown  backwards,  and  is  easily  brought  into  its 
natural  connexion  with  the  tibia,  but  it  directly 
again  slips  from  its  position.  This  state  produces  a 
considerable  degree  of  weakness  and  fatigue  rn  walk- 
ing, and  the  person  suffers  much  from  exercise.  As 
in  these  cases  there  is  a  superabundant  secretion  of 
synovia,  and  a  distension  of  ligament,  repeated  blis- 
tering is  required  to  promote  absorption ;  and  after- 
wards a  strap  is  to  be  buckled  around  the  upper 
part  of  the  leg,  to  bind  the  bone  firmly  in  its  nat- 
ural situation  ;  a  cushion  may  be  added  behind  the 
head  of  the  bone,  to  give  it  support,  and  at  least 
prevent  the  increase  of  the  malady. 


31 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


Structure  of  the  joint ;  bone, — The  bones  which 
enter  into  the  composition  of  the  ankle-joint  are  the 
tibia,  fibula,  and  astragalus.  The  tibia  forms  an  ar- 
ticulating surface  at  its  lower  part,  which  rests  upon 
the  astragalus ;  there  is  a  projection  on  the  inner 
side  of  the  lower  portion  of  this  bone,  which  forms 
the  malleolus  internus,  and  this  part  is  articulated 
with  the  side  of  the  astragalus.  The  fibula  projects 
beyond  the  tibia  at  the  outer  ankle,  and  forms  there 
the  malleolus  externus,  which  has  also  an  articulating 
surface  for  the  astragalus.  The  astragalus,  which 
is  the  superior  tarsal  bone,  rises  between  the  malle- 
oli and  the  lower  part  of  the  tibia,  and  moves  upon 
it  principally  in  flexion  and  extension  of  the  foot. 

Thus  nature  has  strongly  protected  this  part  of 
the  body,  by  the  deep  socket  formed  by  the  two 
bones  of  the  leg,  and  by  the  ball  of  the  astragalus 
which  is  received  between  them. 

Capsular  ligament, —  A  capsular  ligament,  secret- 
ing synovia  on  its  internal  surface,  joins  the  tibia  and 
fibula  to  the  astragalus.  A  strong  ligament  unites 
the  tibia  to  the  fibula,  but  without  any  intervening 
articular  cavity,  as  the  ligament  proceeds  directly 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


24  3 


from  one  surface  of  bone  and  is  received  into  the 
other. 

Peculiar  ligaments.  —  The  peculiar  ligaments  join- 
ing the  tibia  and  fibula  to  the  tarsus,  consist  of  a 
deltoid  ligament,  which  proceeds  from  the  tibia  to 
the  astragalus,  os  calcls,  and  os  naviculare.  The 
fibula  is  united  at  its  lower  end  bj  three  excessively 
strong  ligaments;  one  anteriorly  from  the  malleolus 
externus  to  the  astragalus,  one  inferiorly  to  the  os 
calcis,  and  the  third  to  the  astragalus  posteriorly ; 
and  it  is  the  strong  union  of  this  bone  which  leads 
to  its  being  more  frequently  fractured  than  dislocat- 
ed ;  and  even  when  the  tibia  is  luxated  the  fibula 
is  fractured  in  two  of  the  species  of  dislocation  of 
the  ankle,  and  generally  in  all ;  but  when  the  tibia 
is  thrown  outwards  I  have  known  the  fibula  escape 
a  fracture. 

Directions  of  dislocatio^is,  —  I  have  seen  the  tibia 
dislocated  at  the  ankle  in  three  different  directions: 
inwards,  forwards,  and  outwards  ;  and  a  fourth  spe- 
cies of  dislocation  is  said  sometimes  to  occur,  viz, 
backwards:  the  foot  has  also  been  known  to  be 
thrown  upwards  between  the  tibia  and  fibula,  by 
the  giving  way  of  the  ligament  which  unites  these 
bones  ;  but  this  accident  is  only  an  aggravated  state 
of  the  internal  dislocation. 


SIMPLE  DISLOCATION   OF    THE  TIBIA  INWARDS. 

Dislocation  inwards;  symptoms, — This  is  the 
most  frequent  of  the  dislocations  of  the  ankle.  The 
tibia  in  this  accident  has  its  internal  malleolus  thrown 
inwards,  and  so  forcibly  projecting  against  the  integ- 
uments as  to  threaten  their  bursting.  The  foot  is 
thrown  outwards,  and  its  inner  edge  rests  upon  the 


244 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


ground.  It  rotates  easily  on  its  axis.  There  is  con- 
siderable depression  above  the  outer  ankle,  much 
pain,  some  crepitus,  often  at  three  inches  from  the 
lower  joints  of  the  fibula  upwards,  facility  of  lateral 
motion  of  the  foot,  and  considerable  tumefaction. 

Dissection,  —  Upon  dissection,  the  internal  appear- 
ances are  as  follow.  The  end  of  the  tibia  rests 
upon  the  inner  side  of  the  astragalus,  instead  of  rest- 
ing on  its  upper  artlculatory  surface  ;  and  if  the  ac- 
cident has  been  caused  from  jumping  from  a  con- 
siderable height,  the  lower  end  of  the  tibia,  where 
it  is  joined  to  the  fibula  by  ligament,  is  split  off,  and 
remains  connected  with  the  fibula,  which  is  also 
broken  from  two  to  three  inches  above  the  joint, 
and  the  broken  end  of  the  fibula  is  carried  down 
upon  the  astragalus,  occupying  the  natural  situation 
of  the  tibia.  The  malleolus  externus  of  the  fibula 
remains  in  its  natural  situation,  with  two  inches  of 
the  fibula  and  the  split  portion  of  the  tibia;  the 
capsular  ligament  attached  to  the  fibula  at  the 
malleolus  externus,  and  the  three  strong  fibular 
tarsal  ligaments,  remain  uninjured. 

This  accident  generally  happens  in  jumping  from 
a  considerable  height,  or  in  running  violently  with 
the  toe  turned  outwards,  when  the  foot  being  sud- 
denly checked  in  its  motion  while  the  body  is  carried 
forwards  upon  it,  the  ligaments  on  the  inner  side  of 
the  ankle  give  way.  It  may  also  be  caused  by  a  fall 
on  that  side,  when  the  foot  is  fixed. 

To  distinguish  a  fracture  of  the  fibula,  the  hand 
must  grasp  the  leg  just  above  the  ankle,  and  the 
foot  must  be  freely  rotated  ;  when,  the  motion  of 
the  foot  being  communicated  to  the  fibula,  pain  will 
be  felt,  and  a  crepitus  perceived. 

Mode  of  reduction.  —  For  the  reduction  of  this 
dislocation,  which  cannot  be  too  soon  accomplished, 
the  patient  is  to  be  placed  upon  a  mattress  properly 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  245 

prepared,  and  is  to  rest  on  the  side  on  which  the 
injury  has  been  sustained  ;  the  surgeon  is  then  to 
bend  the  leg  at  right  angles  with  the  thigh,  so  as  to 
relax  the  gastrocnemii  muscles  as  much  as  possible  ; 
and  an  assistant  grasping  the  foot,  must  gradually 
draw  it  in  a  line  with  the  leg.  The  surgeon  then 
fixes  the  thigh  and  presses  the  tibia  downwards, 
thus  forcing  it  upon  the  articulating  surface  of  the 
astragalus.  Great  force  is  required  if  the  limb  be 
placed  in  the  extended  position,  from  the  resistance 
of  the  gastrocnemii;  and  it  is  pleasing  to  observe, 
^fter  most  violent  attempts  by  others,  a  well-inform- 
ed surgeon  gently  bend  the  limb,  and,  under  a  com- 
paratively slight  extension,  return  the  parts  to  their 
natural  situation. 

Treatment.  —  When  the  limb  has  been  reduced 
it  is  still  to  remain  upon  its  outer  side  in  the  bent 
position,  with  the  foot  well  supported  ;  a  many-tailed 
bandage  is  to  be  placed  over  the  part  to  prevent  it 
from  slipping,  and  this  is  to  be  kept  wet  with  an 
evaporating  lotion.  Two  splints  are  then  to  be  ap- 
plied ;  and  each  is  to  have  a  foot-piece,  to  give  sup- 
port to  the  foot,  prevent  its  eversion,  and  preserve 
it  at  right  angles  with  the  leg.  If  much  inflamma- 
tion succeeds,  leeches  are  to  be  applied  to  the  parts, 
and  the  constitution  will  require  relief  by  taking 
blood  from  the  arm,  and  by  attention  to  the  bowels; 
but  I  shall  say  no  more  on  this  subject  until  I  de- 
scribe compound  dislocation  of  this  joint.  A  person 
who  has  sustained  this  accident  may  be  removed 
from  his  bed  in  five  or  six  weeks,  long  straps  of 
plaster  being  passed  around  the  joint  to  keep  the 
parts  together,  and  he  may  be  suffered  to  walk  on 
crutches;  but  from  ten  to  twelve  weeks  will  elapse 
before  he  has  the  perfect  motion  of  the  foot  ;  and 
much  friction  and  passive  motion  will  be  required 


246  DISLOCATIONS  OF  THE  ANKLE-JOINT. 

after  the  eighth  week  to  restore  the  natural  motion 
of  the  joint. 


SIMPLE  DISLOCATION  OF  THE  TIBIA  FORWARDS. 

Symptoms  ;  dissection^  —  Tn  this  accident  the 
foot  appears  much  shortened  and  fixed,  the  heel  is 
proportionably  lengthened  and  firmly  fixed,  and  the 
toes  are  pointed  downwards.  The  lower  extremity 
of  the  tibia  forms  a  hard  projection  upon  the  upper 
part  of  the  middle  of  the  tarsus,  under  the  project- 
ed tendons,  and  a  depression  is  situated  before  the 
tendon  'Achillis.  On  dissection  the  tibia  is  found  to 
rest  upon  the  upper  surface  of  the  os  naviculare  and 
OS  cuneiforme  internum  ;  quitting  all  the  articulatory 
surface  of  the  astragalus,  excepting  a  small  portion 
on  its  fore  part,  against  which  the  tibia  is  applied. 
The  fibula  is  broken,  and  its  fractured  end  advances 
with  the  tibia,  and  is  placed  by  its  side  :  its  malleolus 
externus  remains  in  its  natural  situation,  but  the  fibu- 
la is  broken  about  three  inches  above  it.  The  cap- 
sular ligament  is  torn  through  on  its  fore  part.  The 
deltoid  ligament  is  only  partially  lacerated,  and  the 
three  ligaments  of  the  fibula  remain  unbroken. 
This  accident  arises  from  a  fall  of  the  body  back- 
wards whilst  the  foot  is  confined,  or  from  that  of  a 
person  jumping  from  a  carriage  in  rapid  motion  with 
the  toe  pointed  forwards. 

Reduction ;  treatment.  —  The  treatment  consists 
in  attending  to  the  following  rules.  The  patient 
should  be  placed  in  bed  on  his  back  ;  one  assistant 
grasps  the  thigh  at  its  lower  part  and  draws  it  to- 
wards the  body,  another  pulls  the  foot  in  a  line  a  lit- 
tle before  the  axis  of  the  leg,  and  the  surgeon  pushes 
the  tibia  back  to  bring  it  into  its  place.    The  same 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  247 


principles  are  held  in  view  in  the  mode  of  reduction 
as  in  the  former,  with  respect  to  the  relaxation  of 
the  muscles.  A  many-tailed  bandage,  dipped  in  an 
evaporating  lotion,  must  be  lightly  applied.  The 
local  and  constitutional  treatment  is  the  same  as  in 
the  dislocation  inwards. 

As  to  position,  it  is  best  to  keep  the  patient  with 
the  heel  resting  on  a  pillow,  and  to  have  a  splint, 
properly  guarded,  on  each  side  of  the  leg,  having 
foot-pieces  to  keep  the  foot  well  supported  at  right 
angles  with  the  leg,  so  as  to  prevent  the  muscles 
again  drawing  it  from  its  place.  As  in  five  weeks 
the  fibula  will  be  united,  there  will  then  be  no  danger 
in  taking  the  patient  from  his  bed,  and  gentle  passive 
motion  may  be  begun. 

The  application  of  a  long  splint  on  each  side,  with 
a  foot-piece  to  each  splint,  and  this  padded  in  such 
a  manner  as  to  give  the  foot  a  direction  inwards,  out- 
wards, or  at  right  angles,  according  to  the  direction 
of  the  dislocation,  answers  better  than  any  other 
mode  of  securing  it.  {Seo  Plate.)  When  this  is 
applied,  the  foot  cannot  escape  from  the  situation  in 
which  the  surgeon  has  placed  it. 

M.  Dupuytren,  of  the  Hotel  Dieu,  a  very  eminent 
surgeon,  has  recommended  a  single  splint,  well  cush- 
ioned, along  the  outer  or  inner  part  of  the  leg,  ac- 
cording to  the  direction  of  the  dislocation,  and  fast- 
ened to  the  leg  and  foot  by  bandages.  —  See  a  plate 
in  Johnson^ s  Medico- Chirurgical  Review. 


PARTIAL  DISLOCATION  OF  THE  TIBIA  FORWARDS. 

Symptoms.  —  This  bone  is  sometimes  partially 
luxated  forwards,  so  as  to  rest  half  on  the  os  navic- 
ulare,  and  half  on  the  astragalus.    The  fibula  in  this 


248 


DISLOCATIONS   OF  THE  ANKLE-JOINT. 


accident  is  broken  :  the  foot  appears  but  little  short- 
ened, nor  is  there  any  considerable  projection  of 
the  heel.  The  following  are  the  signs  of  this  ac- 
cident. The  foot  is  pointed  downAvards,  and  a 
difficuhj  is  experienced  in  the  attempt  to  put  it  flat 
on  the  ground  ;  the  heel  is  drawn  up,  and  the  foot 
is  in  a  great  degree  immovable. 

Case.  —  The  first  case  of  this  kind  which  1  saw 
was  in  a  very  stout  lady,  who  resided  at  Stoke  New- 
ington,  who  had  by  a  fall,  as  she  said,  sprained  her 
ankle.  When  I  examined  the  limb  I  found  the  foot 
immovably  fixed,  pointed  downwards,  and  attended 
with  great  pain  just  above  the  ankle.  I  attempted 
to  draw  the  foot  forwards  and  bend  it,  but  could  not 
succeed.  Some  years  afterwards  I  saw  this  lady  at 
Bishop  Stortford,  walking  upon  crutches;  her  toe 
was  pointed,  and  she  was  unable  to  bring  any  other 
part  of  the  foot  to  the  ground  ;  the  degree  of  dis- 
tortion was  less  than  that  which  occurs  in  the  com- 
plete luxation  of  the  bone  forwards  ;  but  all  tension 
having  now  been  subdued,  the  nature  of  the  injury 
was  more  evident,  though  I  should  not  have  known 
it  decidedly,  without  an  examination  of  a  foot  shown 
to  me  by  ray  friend  and  late  apprentice,  Mr  Tyr- 
rell, who  was  so  kind  as  to  give  me  the  parts  which 
were  taken  from  a  subject  dissected  at  Guy's  Hos- 
pital. The  articular  surface  of  the  lower  part  of 
the  titia  was  divided  into  two  ;  the  anterior  part 
was  seated  upon  the  os  naviculare,  the  posterior 
upon  the  astragalus;  these  two  articulatory  surfaces, 
formed  at  the  lower  extremity  of  the  bone,  had  been 
rendered  smooth  by  friction.  The  fibula  was  found 
fractured.  (See  Plate.)  The  result  of  this  disloca- 
tion clearly  proves  the  necessity  which  exists  in  these 
accidents,  however  slight  they  may  at  first  sight  ap- 
pear, of  not  resting  satisfied  until  the  foot  be  return- 
ed into  its  natural  position,  and  restored  to  its  mo- 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


249 


tion;  for,  if  neglected  in  the  commencement,  severe 
inflammation  and  tension  will  prevent  even  a  forci- 
ble extension  from  being  afterwards  useful ;  and  if 
still  longer  neglected,  the  changes  in  the  state  of 
the  muscles,  and  the  union  of  the  fractured  fibula, 
will  preclude  the  possibility  of  a  reduction,  even 
under  the  most  violent  attempts.  The  mode  of  re- 
duction and  after  treatment  will  in  no  respect  differ 
from  that  required  in  the  perfect  dislocation  of  the 
bone  forwards,  either  in  regard  to  the  relaxation  of 
the  muscles,  the  bandages,  or  the  local  and  constitu- 
tional treatment. 


SIMPLE   DISLOCATION  OF   THE  TIBIA  OUTWARDS. 

Symptoms,  —  This  luxation  is  the  most  dangerous 
of  the  three  ;  for  it  is  produced  by  greater  violence, 
is  attended  with  more  contusion  of  the  integuments, 
more  laceration  of  ligament,  and  greater  injury  to 
the  bone,  than  ejther  of  the  others.  The  foot  is 
thrown  inwards,  and  its  outer  edge  rests  upon  the 
ground.  The  malleolus  externus  projects  the  integ- 
uments of  the  ankle  very  much  outwards,  and  forms 
so  decided  a  prominence  that  the  nature  of  the  in- 
jury cannot  be  mistaken.  The  foot  and  toes  are 
pointed  downwards 

Dissection.  —  In  the  dissection  of  this  accident,  it  is 
found  that  the  malleolus  internus  of  the  tibia  is 
obliquely  fractured  and  separated  from  the  shaft  of 
the  bone.  The  fractured  portion  sometimes  consists 
only  of  the  malleolus;  at  others,  the  fracture  passes 
obliquely  through  the  articular  surface  of  the  tibia, 
which  is  thrown  forwards  and  outwards  upon  the 
astragalus,  before  the  malleolus  externus.  The 
astragalus  is  sometimes  fractured,  and  the  lower 
32 


250  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


extremity  of  the  fibula  is  broken  into  several  splint- 
ers. The  deltoid  ligament  remains  unbroken,  but 
the  capsular  ligament  is  torn  on  its  outer  part.  The 
three  fibular  tarsal  ligaments  remain  whole  in  most 
cases,  but  when  the  fibula  is  not  broken  they  are 
ruptured.  None  of  the  tendons  are  lacerated,  and 
internal  hgemorrhages  scarcely  ever  occur  to  any 
extent,  as  the  large  arteries  generally  escape  inju- 
ry. This  accident  happens  either  by  the  passage  of 
a  carriage-wheel  over  the  leg,  or  by  a  distortion  of 
the  foot  in  jumping  or  falling. 

Reduction.  —  The  mode  of  reduction  consists  in 
placing  the  patient  upon  his  back,  in  bending  the 
thigh  at  right  angles  with  the  body,  and  the  leg  at 
right  angles  with  the  thigh;  the  thigh  is  then  grasp- 
ed under  the  ham  by  one  assistant,  and  the  foot  by 
another;  and  thus  an  extension  is  made  in  the  axis 
of  the  leg,  whilst  the  surgeon  presses  the  tibia  in- 
wards towards  the  astragalus.  The  limb,  in  the 
simple  dislocation,  is  to  be  laid  upon  its  outer  side, 
resting  upon  splints,  with  foot-pieces;  and  a  pad  is 
to  be  placed  upon  the  fibula,  just  .above  the  outer 
ankle,  and  extending  a  few  inches  upwards,  so  as  in 
some  measure  to  raise  that  portion  of  the  leg  and 
support  it;  and  to  prevent  the  slipping  of  the  tibia 
and  fibula  IVom  the  astragalus,  as  well  as  to  lessen 
the  pressure  of  the  malleolus  externus  upon  the 
integuments  where  they  have  sustained  injury. 

Treatment. — The  local  and  general  treatment  will 
be  the  same  as  in  the  former  cases,  although  more 
depletion  is  required,  as  greater  inflammation  suc- 
ceeds ;  the  greatest  care  is  necessary  to  prevent  the 
foot  from  being  twisted  inwards,  or  pointed  down- 
wards, as  either  position  prevents  the  limb  from 
being  afterwards  useful ;  and  this  precaution  is  ef- 
fected by  having  two  splints,  with  a  foot-piece  to 
each,  padded  and  applied  to  the  ankle  on  the  outer 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  251 


side  of  the  leg.  Passive  motion  should  be  given  to 
the  joint  in  six  weeks  after  the  accident,  when  the 
patient  may  rise  from  his  bed,  and  be  allowed  to 
walk  upon  crutches,  unless  impeded  by  great  swelling 
of  the  ankle.  In  the  generality  of  these  cases,  from 
ten  to  twelve  weeks  elapse  before  the  cure  is  com- 
plete. 


COMPOUND  DISLOCATION  OF  THE  ANKLE-JOINT. 

Opening  into  the  joint,  —  These  accidents  take  place 
in  the  same  direction  as  the  simple  dislocations,  and 
the  bones  and  ligaments  suffer  in  the  same  manner 
as  in  those  dislocations.  The  difference,  therefore, 
in  these  cases  is,  that  the  joint  is  laid  open  by  a 
wound  in  the  integuments  and  ligaments,  opposite 
to  the  laceration  of  the  skin,  by  which  the  synovia 
escapes,  and  through  which  the  ends  of  the  bone 
protrude;  this  opening  in  the  integuments  is  gener- 
ally occasioned  by  the  bone,  but  sometimes  by  the 
pressure  of  some  uneven  surface  on  which  the  limb 
may  have  been  thrown. 

Local  eff^ects,  —  The  bones  being  replaced  by  the 
means  which  are  employed  in  the  simple  dislocation, 
the  effects  of  this  accident  upon  the  parts  composing 
the  joint  are  as  follow :  The  synovia,  as  1  have 
stated,  escapes  by  a  large  wound  through  the  lace- 
rated ligament;  in  a  few  hours  inflammation  begins; 
and  when  an  additional  quantity  of  blood  is  first  de- 
termined to  the  part,  an  abundant  secretion  issues 
from  this  membrane,  and  is  discharged  through  the 
Avound;  the  ligaments  participate  in  the  inflammation, 
as  well  as  the  extremities  of  the  bones  which  enter 
into  the  composition  of  the  joint.  The  inflammation 
of  the  internal  secreting  surface  of  the  ligament,  in 


252  DISLOCATIONS  OF  THE  ANKLE-JoiNT. 


about  five  days,  proceeds  to  suppuration ;  at  first 
but  little  matter  is  discharged,  but  it  continues  in- 
creasing until  it  becomes  very  abundant,  and  the 
lacerated  parts  of  the  ligaments  and  periosteum  also 
secrete  matter.  Under  this  process  of  suppuration, 
the  cartilages  become  partially  or  wholly  absorbed, 
but  in  general  only  partially  ;  for  the  ulceration  of 
the  cartilage  is  a  very  slow  process,  attended  with 
severe  constitutional  irritation,  and  often  lays  the 
foundation  for  exfoliation  of  the  extremities  of  the 
bones.  When  the  cartilages  are  absorbed,  granula- 
tions arise  from  the  surface  of  the  bones  and  from 
the  inner  side  of  the  ligament,  and  these  inosculate 
and  fill  the  cavity  between  the  extremities  of  the 
bones.  Sometimes  we  find  after  accidents  to  joints,  that 
the  adhesive  process  occurs  at  one  part,  and  that  the 
cartilage  is  not  absorbed  ;  whilst  granulations  are 
formed  at  others,  where  the  cartilage  was  removed 
by  ulceration;  and  I  have  seen,  after  inflammation 
in  joints,  the  cartilages  remain,  and  their  surfaces 
adhere. 

Neither  this  inosculation  of  granulations,  noi*  the 
process  of  adhesion,  leads  to  permanent  anchylosis ; 
for  if  passive  motion  be  begun  as  soon  as  the  parts, 
from  cessation  of  pain  and  inflammation,  will  permit, 
motion  will  be  restored,  not  always  entirely,  but  with 
very  little  diminution  ;  and  the  other  joints  of  the 
tarsus  will  acquire  such  an  extent  of  motion  as  to 
render  the  deficiency  in  the  mobility  of  the  ankle- 
joint  but  little  apparent.  The  aperture  in  the  liga- 
ment is  filled  by  granulations ;  and  with  respect  to 
the  extremities  of  the  bone,  when  they  are  joined 
by  ossific  union,  this  junction  is  effected  by  the  de- 
posit of  cartilage,  and  by  a  secretion  of  phosphate 
of  lime,  in  the  usual  manner  in  which  bones  are 
formed  and  repaired. 

Thus,  then,  the  compound  dislocation  of  the  ankle 


DISLOCATIONS   OF  THE  ANKLE-JOINT. 


253 


leads  to  inflammation  over  a  very  extensive  secreting 
surface;  it  produces  an  extended  suppuration  over 
the  lining  of  the  joint,  which  occasions  much  con- 
stitutional derangement  :  and,  further,  it  hecomes 
the  source  of  an  ulcerative  process,  more  or  less  ex- 
tensive according  to  the  treatment  pursued;  by  this 
the  cartilage  is  partly  or  wholly  removed,  and  an 
irritative  fever  is  supported  for  a  great  length  of 
time  ;  and  the  ulceration  sometimes  extends  over 
the  extremities  of  the  dislocated  bones,  and  leads  to  a 
greatly  augmented  constitutional  irritation,  and  to 
protracted  disease  from  exfoliation. 

These  local  effects  are  accompanied  by  the  common 
symptoms  of  constitutional  excitement.  In  two  or 
three  days  from  the  accident,  or  sometimes  as  early 
as  twenty-four  hours,  the  patient  complains  of  pain 
in  his  back  and  in  his  head,  showing  the  influence 
of  the  accident  on  the  brain  and  spinal  marrow. 
The  tongue  is  furred:  white,  if  the  irritation  be 
slight;  yellow,  if  greater ;  and  brown,  almost  to 
blackness,  if  it  be  considerable.  The  stomach  is  dis- 
ordered ;  there  is  loss  of  appetite,  nausea,  and  some- 
times vomiting.  Secretion  ceases  in  the  intestines 
and  in  the  glands  connected  with  them,  as  the  liver, 
etc.;  costiveness  is  therefore  an  attendant  symptom. 

The  skin  has  its  secretion  stopped ;  it  becomes 
hot  and  dry  ;  the  kidneys  also  have  their  secretion 
diminished  :  the  urine  is  high  coloured,  and  small  in 
quantity.  The  heart  beats  more  quickly  and  the 
pulse  becomes  hard,  which  is  the  pulse  of  consti- 
tutional irritation  from  local  inflammation,  and  in 
great  degrees  of  this  excitement  it  becomes  irregu- 
lar and  intermittent ;  the  respiration  is  quicker,  in 
sympathy  with  the  quicker  circulation ;  the  nervous 
system  becomes  additionally  affected,  in  high  degrees 
of  local  irritation ;  restlessness,  watchfulness,  deli- 
rium, subsultus  tendinum,  and  sometimes  tetanus  oc- 


254        DISLOCATIONS   OF  THE  ANKLE-JOINT. 


cur.  These  are  the  usual  effects  of  local  irritation 
upon  the  constitution,  occurring  in  different  degrees, 
:according  to  the  violence  of  the  injury,  the  irrita- 
bility of  the  system,  and  the  powers  of  restoration. 

Cause  of  the  symptoms  ;  principle  of  cure,  —  The 
causes  of  the  violence  of  these  symptoms  are,  the 
wound  which  is  made  into  the  joint,  and  the  great 
efforts  required  for  its  repair :  for  when  there  is  no 
vround,  and  the  process  of  adhesion  can  unite  the 
part,  little  local  inflammation  or  constitutional  irrita- 
tion can  occur ;  and  if  this  be  the  cause  of  the  vio- 
lence of  the  symptoms,  the  principle  in  the  treatment 
of  this  accident  is  easily  comprehended ;  it  consists 
in  closing  the  wound  as  completely  as  possible,  to 
^issist  nature  in  the  adhesive  process  by  which  the 
wound  is  to  be  closed,  and  to  render  suppuration  and 
granulation  less  necessary  for  the  union  of  the  opened 
joint. 

Is  amputation  required,  —  The  first  question  which 
arises  upon  this  subject  is  the  following:  Is  amputa- 
tion generally  necessary  in  compound  dislocations  of  the 
ankle?  My  answer  is,  certainly  not.  Thirty  years 
ago  it  was  the  practice  to  amputate  limbs  for  this 
accident ;  and  the  operation  was  then  thought  abso- 
lutely necessary  for  the  preservation  of  life  by  some 
of  our  best  surgeons ;  but  so  many  limbs  have  been 
saved  of  late  years,  indeed,  I  may  say,  so  great  a 
majority  of  these  cases  exist,  that  such  advice  would 
now  be  considered  not  only  injudicious  but  cruel.  It 
is  far  from  being  my  intention  to  state  that  amputation 
is  never  required;  I  have  only  to  observe,  that  in 
the  great  number  of  these  accidents  the  operation  is 
unnecessary. 

But  before  I  give  the  proofs  of  what  I  have  ad- 
vanced, I  snail  state  the  mode  of  treatment  which  is 
to  be  pursued  in  these  cases. 

Treatment;  artery  divided. —  When  the  surgeon 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  255 


examines  the  limb,  he  finds  a  wound  of  greater  or 
less  extent,  according  to  the  degree  of  the  injury. 
The  extremity  of  the  tibia  projects  if  the  dislocation 
of  the  tibia  be  inwards;  and  the  tibia  and  fibula  are 
protruded,  if  the  dislocation  of  the  former  be  at  the 
outer  ankle.  The  ends  of  the  bones  are  often  cov- 
ered with  dirt  from  their  having  reached  the  ground. 
The  foot  is  loosely  hanging  on  the  inner  or  outer 
side  of  the  leg,  according  to  the  direction  of  the  dis- 
location. Sometimes,  though  very  rarely,  a  large 
artery  will  be  divided;  and  it  is  surprising  that  the 
posterior  tibial  artery  so  generally  escapes  laceration; 
the  anterior  tibial  being  the  only  vessel  I  have 
known  to  be  torn.  The  arrest  of  haemorrhage  is 
the  first  object;  and  for  this  purpose,  if  the  anterior 
tibial  artery  be  Avounded,  it  must  be  secured  by  liga- 
ture. The  extremity  of  the  bone  is  to  be  washed 
with  warm  water,  as  the  least  extraneous  matter 
admitted  into  the  joint  will  produce  and  support  a 
suppurative  process;  and  the  utmost  care  should  be 
taken  to  remove  every  portion  of  it  adhering  to  the 
end  of  the  bone. 

Loose  pieces  of  hone;  integuments,  —  If  the  bone 
be  shattered,  the  finger  is  to  be  passed  into  the  joint, 
and  the  detached  pieces  are  to  be  removed ;  but 
this  is  to  be  done  in  the  most  gentle  manner  possible, 
so  as  not  to  occasion  unnecessary  irritation.  If  the 
wound  be  so  small  as  to  admit  the  finger  with  difii- 
culty,  and  if  small  pieces  of  bone  can  be  felt,  the 
integuments  should  be  divided  with  a  scalpel,  to 
allow  of  such  portions  being  removed  without  vio- 
lence ;  the  incision  should  be  so  made  as  to  leave 
the  joint  with  as  much  covering  of  integument  as 
possible.  The  integuments  are  sometimes  nipped 
into  the  joint  by  the  projecting  bone  ;  and  then  it 
cannot  be  reduced  without  making  an  incision,  to 
allow  the  skin  to  be  drawn  from  under  the  bone  ; 


256  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


and  when  the  edges  of  the  incised  wound  are  after- 
wards brought  together,  no  additional  evil  arises 
from  the  extension  of  the  wound. 

Reduction,  —  The  mode  of  reducing  the  bone  is, 
in  other  respects,  similar  to  that  which  I  have  al- 
ready described  when  speaking  of  simple  disloca- 
tion ;  by  bending  the  leg  upon  the  thigh,  so  as  to 
relax  the  muscles  before  the  extension  is  made. 
When  the  bone  has  been  reduced,  a  piece  of  lint  is 
to  be  dipped  in  the  patient's  blood,  and  applied  wet 
over  the  wound,  upon  which  the  blood  coagulates, 
and  forms  the  most  natural,  and,  as  far  as  I  have 
seen,  the  best  covering  for  the  wound.    A  many- 
tailed  bandage  i&  then  applied,  the  portions  of  which 
should  not  be  sewn  together,  but  passed  under  the 
leg,  so  that  any  one  piece  may  be  removed  when  it 
becomes  stiff ;  and  by  fixing  another  to  its  end,  the 
application  may  always  be  renewed  without  any  dis- 
turbance to  the  limb:  this  bandage  is  to  be  kept 
constantly  wet  with  spirits  of  wine  and  water.  A 
hollow  splint,  with  a  foot-piece  at  right  angles,  is  to 
be  applied  on  the  outer  side  of  the  leg,  in  the  dis- 
location inwards,  and  the  leg  is  to  rest  upon  its  outer 
side  :  but  in  the  dislocation  outwards,  it  is  best  to 
keep  the  limb  upon  the  heel,  with  a  splint  and  foot- 
piece  both  upon  the  outer  and  the  inner  side  :  and 
an  aperture  in  the  splint  opposite  to  the  wound. 

Constitutional  treatment.  —  In  each  dislocation  the 
patient's  knee  is  to  be  slightly  bent,  to  relax  the 
gastrocnemius  muscle.  The  foot  must  be  carefully 
prevented  from  being  pointed ;  great  care  being 
taken  to  preserve  it  at  right  angles  with  the  leg, 
otherwise  the  limb  will  be  useless  when  the  wound 
is  healed.  The  patient  is  to  be  placed  on  a  mat- 
tress, and  a  pillow  is  to  reach  from  half  way  above 
the  knee  to  beyond  tlie  foot,  and  another  is  to  be 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  257 


rolled  under  the  hip,  to  support  the  upper  part  of 
the  thigh-bone. 

Blood-letting;  purging,  —  Blood-letting  must  be 
adopted  J  or  not,  according  to  the  powers  of  the  con- 
stitution ;  as  it  is  necessary  to  bear  in  mind  that  the 
patient  has  a  great  trial  of  his  powers  to  undergo, 
and  will  require  throughout  the  process  of  restora- 
tion, all  the  support  which  his  strength  can  receive. 
Purgatives  must  also  be  used  with  the  utmost  cau- 
tion ;  for  there  cannot  be  a  worse  practice,  when  a 
limb  has  been  placed  in  a  good  position,  and  adhe- 
sion is  proceeding,  than  to  disturb  the  processes  of 
nature  by  the  frequent  changes  of  position  which 
purges  produce  ;  and  I  am  quite  sure,  that  in  cases 
of  compound  fracture,  I  have  seen  patients  destroyed 
by  their  frequent  administration.  That  which  is  be 
done  by  bleeding,  and  emptying  the  bowels,  should 
be  effected  as  soon  as  is  possible  after  the  accident, 
before  the  adhesive  inflammation  arises  ;  after  which 
the  liquor  ammoniae  acetatis,  and  tinctura  opii,  form 
the  patient^s  best  medicine,  with  a  slight  aperient  at 
intervals. 

Secondary  treatment.  —  If  the  patient  complain  of 
considerable  pain  in  the  part,  in  four  or  five  days, 
the  bandage  may  be  raised  to  examine  the  wound  ; 
and  if  there  be  much  inflammation,  a  corner  of  the 
lint  should  be  lifted  from  the  wound,  to  give  vent  to 
any  matter  which  may  be  formed;  but  this  ought  to 
be  done  with  great  circumspection,  as  there  is  a 
danger  of  disturbing  the  adhesive  process,  if  that 
be  proceeding  without  suppuration.  By  this  local 
treatment,  it  will  every  now  and  then  happen  that 
the  wound  will  be  closed  by  adhesion ;  but  if  in 
a  few  days  it  be  not,  and  if  suppuration  take  place, 
the  matter  should  have  an  opportunity  of  escaping; 
and  the  lint  being  removed,  simple  dressing  should 
be  applied.  After  a  week  or  ten  days,  if  there  be 
33 


258 


DISLOCATIONS   OF    THE  ANKLE-JOIKT. 


suppuration  with  much  surrounding  inflammation, 
poultices  should  be  applied  upon  the  wound,  leeches 
in  its  neighbourhood,  and  upon  the  limb  at  a  dis- 
tance, and  the  evaporating  lotion  should  be  still  em- 
ployed ;  but  as  soon  as  the  inflammation  is  lessened, 
the  poultices  should  be  discontinued,  as  they  en- 
courage too  much  secretion,  and  relax  the  blood- 
vessels of  the  part,  so  as  to  prevent  the  restorative 
process. 

Result.  —  If  the  cure  proceeds  favourably,  in  a 
few  weeks  the  wound  is  healed  with  little  suppura- 
tion ;  if  less  favourably,  a  copious  suppuration  takes 
place,  the  wound  is  longer  in  healing,  and  exfoliation 
of  portions  of  the  extremity  of  the  bone  still  fur. her 
retards  the  cure.  The  motion  of  the  joint  is  not 
always  lost;  it  is  sometimes  in  a  great  degree  re- 
stored ;  but  this  depends  upon  the  greater  or  less 
extent  of  suppuration  or  ulceration.  Under  the 
most  favourable  circumstances,  three  months  gener- 
ally elapse  before  the  patient  can  walk  with  crutches; 
in  many  cases,  however,  a  greater  length  of  time  is 
required  :  he  bears  upon  the  foot  at  different  peri- 
ods of  time,  according  to  the  degree  of  injury  sus- 
tained, as  in  compound  fracture,  when  adhesion  is 
not  at  first  produced.  In  compound  dislocations,  of 
course,  the  patient  is  longer  in  recovering. 

I  shall  now  proceed  to  state  the  cases  which 
have  induced  me  to  say  that  amputation,  as  a  gen- 
eral rule,  is  improper. 

The  circumstances  which  led  me  to  doubt  the 
soundness  of  the  opinion,  which  recommended  in- 
discriminate amputation,  were  these:  — 

Case, —  I  was,  many  years  since,  going  into  the 
country  with  a  friend  of  mine,  and  we  met  with  a 
surgeon  in  our  journey  who  put  this  question  :  '  How 
do  you  act  in  compound  dislocations  of  the  ankle- 
joint  T  I  do  not  recollect  the  reply,  but  he  proceeded 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


259 


to  say,  '  I  have  had  a  case  of  compound  dislocation 
of  the  ankle-joint  under  niy  care,  in  which  I  told 
the  patient  he  must  lose  his  limb  :  not  approving 
this  advice,  his  friends  sent  for  another  surgeon, 
who  said  he  thought  he  could  save  it  :  the  patient 
placed  himself  under  his  care,  and  the  man  is  re- 
covering.' 

About  thirty  years  ago  I  received  from  Mr  Lynn, 
of  Woodbridge,  now  Dr  Lynn  of  Bury  St  Edmunds, 
the  astragalus  of  a  man  broken  into  two  pieces, 
which  he  had  taken  from  a  dislocated  ankle-joint. 
His  letter  is  as  follows:  — 

Case.  —  Dear  Sir:— ^J.  York,  aged  thirty-two 
years,  being  pursued  by  some  bailiffs,  jumped  from 
the  height  of  several  feet  to  avoid  them.  The  ti- 
bia and  a  part  of  the  astragalus  protruded  at  the 
inner  ankle.  1  immediately  returned  the  parts  into 
their  natural  situation.  Suppuration  ensued  ;  and  in 
five  weeks  a  portion  of  the  astragalus  separated, 
and  another  piece  a  week  afterwards,  which,  when 
joined,  formed  the  ball  of  that  bone.  In  three 
months  the  joint  was  filled  with  granulations  :  it  soon 
afterwards  healed,  and  the  man  recovered  with  a 
good  use  of  the  hmb. 

Your's,  etc., 

James  Lynn. 

I  attended  a  compound  dislocation  of  the  ankle- 
joint,  in  the  year  1797,  with  Mr  Battley,  tlien  prac- 
tising as  a  surgeon  in  St  Paul's  Ghurch-yard,  now 
an  eminent  chemist  and  druggist  in  Fore-street.  An 
account  of  this  case  I  shall  give  in  the  words  of  Mr 
Battley. 

(Jase,  accompanied  with  insanity,  —  In  the  month 
of  September,  1797,  a  gentleman  lodging  in  Duke^ 


260 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


street,  Smithfield,  in  a  fit  of  insanity  threw  himself 
from  a  two-pair  of  stairs  window  into  the  street,  his 
feet  first  reaching  the  ground.  He  rose  without 
help,  knocked  violently  at  the  outer  door  of  the 
house,  and  ascended  the  stairs  without  the  least  as- 
sistance, bolted  the  door  after  him  and  got  into  bed. 
He  refused  to  open  the  door,  and  it  was  obliged  to 
be  forced.  A  neighbouring  surgeon  was  sent  for, 
who,  on  viewing  the  case,  proposed  an  immediate 
amputation,  which  was  not  acceded  to  by  his  friends; 
but  Mr  Cooper  and  myself  were  requested  to  take 
charge  of  the  case.  On  examination  there  was 
found  a  compound  dislocation  of  the  ankle-joint. 
The  tibia  was  thrown  on  the  inner  side  of  the  foot ; 
and  when  the  finger  was  passed  into  the  wound,  the 
astragalus  was  discovered  to  be  shattered  into  a 
number  of  pieces.  The  loose  and  unconnected  por- 
tions of  bone  were  removed,  and  the  tibia  was  re- 
placed ;  after  which,  lint,  dipped  in  the  oozing  blood, 
was  wrapped  around  the  lacerated  parts,  and  the 
limb  was  placed  on  its  outer  side,  with  the  knee 
considerably  bent.  The  parts  were  ordered  to  be 
kept  cool  by  the  frequent  application  of  evaporating 
lotion. 

Mental  symptoms  improve.  —  The  patient  remain- 
ed as  quiet  as  could  be  expected  from  a  person  in 
his  state  of  mind  until  the  third  or  fourth  day,  when 
a  considerable  inflammation  appeared  in  the  joint, 
and  greatly  increased  the  previous  irritable  state  of 
his  constitution.  Leeches,  fomentations  and  poul^ 
tices  were  applied  to  the  limb,  blood  was  taken 
from  the  arm,  purgative  medicines  were  given,  and 
afterwards  saline  medicines  with  sudorifics.  Extent 
sive  suppuration  ensued,  and  continued  for  six  weeks 
pr  two  months,  when  it  began  to  lessen,  and  healthy 
granulations  appeared  on  the  whole  wounded  sur- 
faces ;  about  this  time  the  state  of  hig  mind  began 


DISLOCATIONS  OF  THE   ANKLE-JOINT.  261 

to  improve,  and  it  continued  to  amend  as  his  leg  ad- 
vanced in  recovery.  At  the  end  of  four  or  five 
months  the  suppurated  parts  had  filled  up,  the  joint 
healed,  and  his  mind  recovered  its  natural  tone.  At 
the  end  of  nine  months  he  returned  to  his  employ- 
ment, but  the  ankle-joint  was  stiff.  In  two  years  he 
had  so  far  recovered  as  to  walk  without  the  aid  of 
a  stick;  and  at  the  end  of  three  or  four  years  was 
able  to  pursue  his  avocations  nearly  as  well  as  at  any 
former  period  of  his  life. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS, 

Case.  —  I  was  sent  for  on  August  11th,  1814,  by 
Mr  Richards,  of  Seale,  in  Kent,  to  visit  Mr  Knowles, 
a  farmer,  residing  at  Tytham  Farm,  aged  forty-eight, 
who  having  been  thrown  from  his  chaise  against  the 
hinder  wheel  of  a  wagon,  had  dislocated  the  tibia 
inwards,  and  fractured  both  the  tibia  and  fibula. 

Mr  Richards,  who  was  immediately  called  to  the 
case,  reduced  the  dislocation,  and  endeavoured  to 
heal  the  wound  by  adhesion.  When  I  saw  Mr 
Knowles,  which  was  ten  days  after  the  accident, 
the  wound  wore  a  favourable  aspect.  The  dis- 
charge was  abundant,  but  not  in  a  degree  to  excite 
alarm  ;  and  all  I  had  to  do  was  to  praise  the  judg- 
ment which  had  led  to  the  preservation  of  the 
limb,  and  to  direct  the  continuance  of  the  means 
which  had  been  employed  for  that  purpose. 

Before  I  ventured  to  state  the  case  to  the  public 
I  wrote  to  Mr  Richards,  who  informed  me  that  Mr 
Knowles's  wound  was  perfectly  healed,  and  that  he 
walks  without  the  use  of  a  stick, 


262 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


COMPOUND   DISLOCATION    OF  THE  TIBIA  OUTWARDS. 

For  the  following  details  I  am  obliged  to  Mr 
Rowley,  apprentice  to  Mr  Chandler,  Surgeon  at  St 
Thomas's  Hospital. 

Case ;  integuments  confined  between  the  bones,  — 

Dear  Sir:  —  In  answer  to  your  inquiries,  I  beg 
leave  to  forward  jou  the  particulars  of  Elizabeth 
Chisnell's  case,  who  was  admitted  into  St  Thomas's 
Hospital,  on  Saturday,  May  29,  1819,  with  a  com- 
pound dislocation  of  the  left  ankle-joint  outwards, 
occasioned  by  her  slipping  from  the  foot-path  into 
the  road-way.  The  wound  communicating  with  the 
Joint  was  situated  upon  the  outer  part  of  the  leg, 
and  was  about  four  inches  in  extent,  through  which 
the  fibula  projected  two  inches,  but  it  was  not  frac- 
tured; the  ligaments  connecting  the  malleolus  ex- 
ternus  and  the  astragalus  were  lacerated.  From 
the  inclination  of  the  sole  of  the  foot  inwards,  the 
whole  articulating  surface  of  the  joint  was  so  dis- 
placed as  to  allow  two  fingers  to  pass  readily  across; 
and  on  examination,  I  found  the  extremity  of  the 
tibia  fractured.  The  parts  were  easily  returned  to 
their  original  situation  by  extending  the  foot,  the 
leg  having  been  first  bent  upon  the  thigh.  During 
the  reduction,  the  integuments  became  confined  be- 
tween the  malleolus  externus  and  the  astragalus,  so 
as  to  require  an  incision  upwards  by  the  side  of  the 
fibula,  to  accomplish  the  extrication;  that  being 
effected,  its  lips  were  brought  together  by  four 
sutures,  and  straps  of  adhesive  plaster.  Splints 
were  applied  ;  and,  to  subdue  the  consequent  inflam- 
mation, the  common  application  was  used. 

June  1.  The  adhesive  plasters  and  sutures  were 
removed,  because  the  wound  and  adjacent  soft  parts 


DISLOCATIONS   OF  THE  ANKLE-JOINT. 


263 


around  the  ankle  were  in  a  sloughing  state.  Poultices 
of  linseed  meal  were  ordered  to  be  used  daily. 

June  5.  The  sloughs  are  separated;  the  sore  is 
granulating;  the  discharge  profuse.  A  collection  of 
matter  has  formed  upon  the  inside  of  the  leg,  which 
was  discharged  by  puncture.  The  wound  Was  or- 
dered to  be  dressed,  and  a  roller  was  gently  applied. 
The  constitution  during  this  time  was  but  little  af- 
fected. Bark  and  'jDorter  were  ordered  by  Mr 
Chandler. 

August  7.  The  wounds  are  almost  healed.  The 
girl  sits  up  daily,  and  in  a  few  days  she  will  be  al- 
lowed to  walk. 

During  the  progress  of  her  cure,  the  constitutional 
disturbance  has  been  trifling,  indeed,  not  more  than 
in  some  favourable  cases  of  simple  fracture  :  it  may 
be  also  well  to  observe  that  her  bowels  were  regular 
during  the  whole  time,  so  as  to  preclude  the  neces- 
sity of  any  laxative  medicine,  nor  did  she  take  any 
other  medicine  than  the  bark. 

I  remain  your's,  etc., 

Southwark.  R.  Rowlev. 


CdMPOUND  DISLOCATION   OF  THE  TIBIA  INWARDS. 

The  following  accident  I  was  requested  to  visit, 
by  Mr  Clarke,  surgeon,  Great  Turnstile,  Lincoln's 
Inn  Fields,  who  had  the  kindness  to  send  me  the 
particulars. 

Case, — ^  Mr  George  Caruthers,  aged  tw^enty-two 
years,  had  a  compound  dislocation  of  the  ankle-joint 
inwards,  with  frac(ure  of  the  tibia,  on  October  the 
6th,  1817.  The  accident  was  occasioned  by  the 
overturning  of  a  stage  coach  at  Kilburn,  from  whence 
he  was  brought  to  his  house  at  Lambeth.    The  end 


264  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


of  the  tibia  projected  through  the  integuments  of 
the  inner  ankle,  to  the  extent  of  from  two  by  three 
inches,  and  the  bone  was  tightly  embraced  by  the 
skin.  The  tibia  was  fractured,  only  a  small  portion 
of  it  remaining  attached  to  the  joint ;  the  bleeding 
was  stated  to  have  been  copious,  but  it  had  subsided 
before  Mr  Clarke  saw  him.  The  fibula  was  badly 
fractured. 

Reduction;  constitutional  treatment,  —  For  the  re- 
duction of  the  protruded  parts  it  became  necessary 
to  make  an  incision  in  the  integuments,  to  loosen 
them  on  the  tibia;  and  when  the  bone  was  restored 
to  its  place^  simple  dressings  were  spread  over  the 
w^ound.  Splints  and  a  many-tailed  bandage,  wetted 
with  an  evaporating  lotion,  were  applied,  and  the 
limb  was  placed  in  the  slightly  bent  position  upon 
a  quilted  pillow*  Bleeding  was  employed,  gentle 
purgatives  given,  and  saline  medicines.  Symptoms 
of  great  constitutional  excitement  naturally  arose 
from  so  severe  a  local  injury.  Abscesses  formed  on 
the  leg,  and  some  exfohations  materially  retarded 
the  cicatrization  of  the  wound,  producing  also  con* 
siderable  exhaustion  of  the  patient's  strength. 
Openings  were  made  into  the  abscesses,  adhesive 
straps  were  placed  over  the  wounds,  and  lotions 
were  applied  on  linen,  under  oiled  silk,  which  pre- 
served the  parts  constantly  wet.  Bark  and  wine 
were  given  with  occasional  aperients.  Mr  Caruthers 
left  town  on  October  the  6th,  1818,  having  then  a 
small  opening  on  each  side  of  the  limb,  and  suffering 
occasional  pain ;  but  his  general  health  had  been 
good  for  some  months  previous.  In  January  last,  a 
considerable  portion  of  bone  came  away,  and  the 
sore  immediately  healed  and  has  so  continued ;  he 
has  been  ever  since  free  from  pain,  and  is  now  in 
better  health  than  before  the  accident.  He  employs 
himself  in  superintending  a  farm,  around  which  he 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


265 


walks  with  one  crutch  and  a  stick,  but  if  the  ground 
be  level,  with  a  stick  only ;  and  the  limb  is  becoming 
daily  more  and  more  useful.* 

To  Mr  Somerville,  of  the  Stafford  Infirmary,  I 
am  indebted  for  the  following  letter. 

Cases.  —  Dear  Sir:  —  I  take  shame  to  myself  for 
not  having  answered  your  obliging  queries  sooner,  as 
to  the  cases  of  compound  dislocation  of  the  ankle 
which  have  fallen  under  my  care  ;  but  the  fact  is,  I 
wished  to  give  you  my  answer  in  the  most  authentic 
form,  by  sending  you  a  transcript  of  the  cases  from 
the  minute  books  of  the  Infirmary;  but  after  having 
caused  the  most  diligent  search  to  be  made  for 
them,  I  have  now  the  mortification  to  learn  that 
they  are  no  where  to  be  found  ;  you  will  allow  me 
therefore  to  plead  this  circumstance  as  the  real 
cause  of  my  seeming  inattention  to  your  wish,  and  at 
the  same  time  to  offer  it  as  an  apology  for  the  want  of 
a  more  detailed  account.  I  have  a  distinct  recollection 
of  two  cases,  though  not  of  the  manner  in  which  the 
accidents  were  produced.  The  first  occurred  about 
fifteen  years  ago,  the  other  a  few. years  later:  they 
were  both  dislocated  inwards,  and  were  both  dis- 
charged cured  ;  the  one  at  the  end  of  the  fifth,  the 
latter  not  till  the  seventh  week.  In  the  first  case 
the  wound,  which  was  lacerated  so  as  to  form  a  flap, 
healed  by  the  first  intention  ;  in  the  latter  it  was 
kept  open  by  the  discharge,  which  was  at  first  puru- 
lent, afterwards  limpid  ;  but  no  untoward  symptom 
supervened  during  the  cure.  The  treatment  in  both 
cases  was  as  follows.  ^ 

*  In  June,  1822,  I  wrote  to  Mr  Caruthers  to  inquire  how  he 
proceeded  ;  and  his  answer  was,  that  he  could  walk  three  or 
four  miles  easily,  and  eight  if  required;  and  that  he  would  not 
exchange  his  injured  leg  for  a  wooden  one  for  the  whole  of 
Europe.  —  A.  C. 

34 


266  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


Use  of  adhesive  straps,  8{c,  —  After  the  reduction 
of  the  bone,  the  patient  was  placed  upon  his  side, 
with  the  limb  in  a  bent  position ;  no  h'gature  was 
used,  but  the  lips  of  the  wound  were  nicely  approxi- 
mated, and  retained  in  situ  by  straps  of  sticking 
plaster,  of  ample  length,  yet  not  sufficient  to  encircle 
the  limb,  lest  they  should,  by  causing  undue  pressure 
on  the  supervening  tension,  excite  too  much  inflam- 
mation, and,  in  consequence,  suppuration.  To  obvi- 
ate, however,  both  tension  and  inflammation  as  much 
as  possible,  a  plaster,  spread  moderately  thick  with 
Kirkland's  defensative,  was  placed  round  and  in  easy 
contact  with  the  ankle,  and  over  the  whole  a  tailed 
bandage  was  loosely  applied.  A  brisk  purgative 
was  given  on  the  following  morning,  and  low  diet 
was  ordered  till  all  danger  of  inflammation  was  over. 
The  adhesive  plaster  was  removed  on  the  second  or 
third  day,  and  was  not  renewed;  but  a  pledget  of 
melilot  digestive  was  placed  over  the  wound,  and  the 
defensative  bandage  applied  as  before.  The  subse- 
quent treatment  consisted  merely  in  the  daily  renewal 
of  the  pledget,  and  the  proper  adjustment  of  the 
plaster  and  bandage,  both  of  which  were  gradually 
drawn  tighter  round  the  limb,  in  proportion  as  the 
danger  of  inflammation  became  less,  and  this  opera- 
lion  was  performed  with  the  view  not  only  to  give 
stability  to  the  joint,  but  also  to  facilitate  the  pro- 
ofress  of  cicatrization. 

The  use  of  the  plaster  after  the  manner  above 
mentioned,  may,  at  first,  appear  to  you  a  singular 
practice,  but,  by  being  spread  very  thick,  it  seldom 
requires  a  renewal  during  the  period  of  cure,  unless 
the  discharge  from  the  wound  should  be  so  great  as 
to  render  a  change  necessary  ;  but  if  it  should  not, 
it  will  appear  obvious  that  there  can  be  no  necessity 
for  disturbing  or  mftving  the  limb  from  its  original 
position,  the  retention  of  which  1  have  ever  consid- 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


267 


ered,  in  cases  both  of  compound  dislocations  and 
compound  fractures,  of  the  highest  importance  to 
facihtate  the  cure.  The  plaster  is  composed  of  two 
parts  of  emp.  plumbi,  and  one  each  of  oil,  vinegar, 
and  chalk  finely  powdered  ;  and  I  have  ever  found 
it  a  most  powerful  repellent  in  all  cases  of  violent 
local  inflammation. 

I  am,  dear  Sir, 
Your  obliged  and  most  obedient  servan 
Stafford^  Aug,  31,  1819.  Henry  SomerviLle. 


COMPOUND  DISLOCATION  OP  THE  TIBIA  OUTWARDS. 

The  following  case  I  received  from  Mr  Scarr, 
surgeon,  of  Bishop's  Stortford. 

Case,  —  Dear  Sir:  —  John  Plumb,  the  subject  of 
the?  following  statement,  was  in  the  thirty-eighth  year 
of  his  age  when  his  accident  took  place,  which  was 
about  seven  years  ago.  He  was  in  the  act  of  ascend- 
ing a  ladder  with  a  sack  of  oats  on  his  shoulders, 
and  had  mounted  ten  feet  from  the  ground,  when  the 
ladder  slipped  from  under  him,  and  he  was  precipi- 
tated to  the  ground,  lighting  on  his  feet,  but  still  sus- 
taining the  sack  of  oats  on  his  shoulders.  I  was 
passing  about  two  hundred  yards  from  the  place  at 
the  moment  when  the  accident  happened,  and  was, 
consequently,  in  immediate  attendance.  On  the  re- 
moval of  his  stocking,  I  found  that  the  tibia  and  fi- 
bula had  penetrated  through  the  integuments  at  the 
outer  ankle,  and  were  lying  on  the  outside  of  the 
foot ;  the  articulatory  surface  of  the  astragalus  had 
penetrated  through  the  integuments  of  the  inner 
ankle,  showing,  on  a  view  of  the  case,  the  foot  nearly 
reversed,  the  bottom  of  the  foot  being  placed  where 
the  side  of  the  foot  is  naturally  situated.  The 


268  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


wounds  through  which  the  surfaces  of  the  bone  had 
penetrated  being  free,  soon  determined  me  in  the 
line  of  conduct  1  should  pursue,  viz,  to  immediately 
reduce  the  joint  to  its  natural  situation  with  as  little 
violence  as  possible,  and  this  was  effected  with  much 
less  difficulty  than  I  expected  ;  the  wounds  were 
brought  close  by  adhesive  straps,  the  limb  placed 
on  its  outer  side,  and  cloths  applied  constantly 
moistened  with  lotion  of  acetate  of  lead.  The 
patient  was  then  bled  to  about  sixteen  ounces ; 
a  saline  diaphoretic  mixture  was  given,  and  attention 
was  paid  to  his  bowels  ;  in  short,  the  antiphlogistic 
plan  was  persevered  in  with  due  regard  to  his  consti- 
tutional powers:  abscesses  took  place  which  were 
opened  in  the  most  favourable  points,  and  after  five 
and  twenty  weeks  the  man  was  convalescent ;  union 
of  the  articulatory  surfaces  took  place,  the  wounds 
healed,  and  the  patient  became  able  to  walk ;  he 
could  not  bear  much  on  his  foot  to  work  till  about 
twelve  months  after  the  accident,  from  which  time 
he  has  constantly  been  labouring  in  his  situation  with 
Mr  Starkis,  a  gentleman  of  respectability  of  this 
town,  and  continues  to  do  so  at  this  time. 

It  is  my  intention  to  send  this  man  up  to  you,  that 
you  may  have  a  full  confirmation  of  the  accident 
from  him,  as  well  as  from  Mr  Cribb,  my  present 
assistant,  who  was  present  at  the  time  of  my  being 
called  to  him,  being  at  that  time  with  his  father,  Mr 
Cribb,  surgeon,  of  this  town,  whom  I  consulted  on 
the  case  at  the  time  of  the  accident,  as  well  as  during 
its  continuance.  Trusting  that  the  statement  and 
result  may  prove  satisfactory  to  your  inquiry, 

I  am,  dear  Sir, 

Your  most  obedient, 
j^ugust  i6th,  1819.  R.  T.  Scarr. 

This  man  was  sent  to  town,  and  I  had  an  oppor* 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


2G9 


tunitj  of  witnessing  the  happj  result  of  Mr  Scan's 
skill  and  attention.  —  A.  C. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS. 

For  the  following  most  interesting  case  I  am  in- 
debted to  a  very  excellent  surgeon,  Mr  Abbott,  at 
Needham  Market,  Suffolk.  It  is  an  admirable  proof 
of  what  may  be  accomplished  in  these  cases  by  ex- 
traordinary skill  and  attention. 

Case;  amputation  refused.  —  April  2.5,  1802,  Mr 
Robert  Cutting,  a  butcher  by  trade,  near  seventy 
years  of  age,  corpulent,  very  intemperate,  and  sub- 
ject to  gout  from  his  youth,  in  a  dispute,  when  in  a 
state  of  intoxication,  was  thrown  violently  to  the 
ground,  and  suffered  a  compound  dislocation  of  the 
tibia  at  the  ankle-joint ;  the  end  of  it  was  forced 
through  the  integuments  nearly  four  inches ;  the 
wound  was  large  and  semicircular;  in  the  struggle 
to  stand  erect,  he  rested  his  weight  upon  the  end  of 
the  bone,  which  was  covered  with  sand  and  dirt ; 
the  cavity  of  the  articulating  surface  of  the  joint 
was  filled  with  blood  and  sand,  the  fibula  fractured 
a  few  inches  above  the  joint,  and  the  foot  completely 
turned  outwards  ;  in  this  state  he  was  placed  in  an 
open  cart,  full  four  miles  from  his  residence,  Somers- 
ham,  in  Suffolk,  about  seven  miles  from  Ipswich. 
It  was  near  five  hours  from  the  time  the  accident 
took  place,  before  surgical  assistance  arrived,  in  the 
middle  of  a  cold  night.  I  attended  with  a  well-in- 
formed pupil  of  mine,  Mr  John  Jefferson,  who  has 
now^  resided  many  years  at  Islington.  A  case  so  for- 
midable, a  large  wound,  the  connecting  ligaments 
lacerated,  the  surfaces  of  the  articulating  parts  long 
exposed  and  much  injured,  led  me  to  conclude,  that 


270  DISLOCATIONS  OF  THE  ANKLE-JOINT* 


it  would  be  impossible  to  save  the  limb,  in  a  consti- 
tution so  disordered ;  however,  no  persuasion  could 
prevail  with  a  mind  obstinate  and  inflexible ;  he 
would  not  submit  to  amputation.  The  surfaces  were, 
as  carefully  and  expeditiously  as  possible,  made  clean 
with  warm  water  ;  the  reduction  was  easily  accom- 
plished, the  lacerated  parts  properly  placed,  and  the 
edges  of  the  wound  nearly  brought  in  apposition, 
without  stitches  or  adhesive  plasters;  the  limb  was 
laid  upon  a  proper  sized  thin  board,  excavated  so 
as  to  take  the  form  of  the  leg,  with  an  opening  to 
receive  the  outer  ankle  ;  this  was  well  padded,  the 
foot-piece  raised  somewhat  higher  than  the  leg ; 
plaits  of  lint,  wetted,  with  the  tinctura  benzoini 
composita,  were  placed  over  the  wound,  which,  in  a 
few  hours,  formed  a  hard  sealed  cap,  of  a  circum- 
ference that  effectually  excluded  the  air ;  a  folded 
flannel  bandage  was  applied  over  the  limb  from  the 
foot  to  the  knee;  and  the  leg  was  laid  in  a  flexed 
position.  V.  S.  3  xij.  A  saline  purge  was  given 
every  two  hours  until  his  bowels  were  relieved ; 
milk  broth  only  was  allowed  for  his  support. 

Sixteen  hours  after  the  dressing  his  bowels  had 
been  properly  evacuated,  and  he  was  tranquil.  Heat 
moderate;  a  moisture  was  spread  over  the  whole 
surface  ;  pulse  8G  ;  and  he  had  some  hours  of  re- 
freshing sleep. 

April  27th.  A  little  heat  was  raised ;  sleep  in- 
terrupted; pulse  96;  surface  moist;  darting  unea- 
siness about  the  ankle  and  foot;  no  thirst;  bowels 
kept  cool,  and  the  same  support  continued  :  common 
saline  medicines  were  resorted  to  every  three  hours. 
Upon  unfolding  the  flannel  some  swelling  appeared 
to  surround  the  ankle  :  a  little  gleety  discharge  had 
escaped  from  beneath  the  lower  part  of  the  dress- 
ing. The  inflammation  did  not  appear  to  be  more 
than  might  be  wished.    Lint,  wetted  with  the  tine- 


DISLOCATIONS  OP   THE  ANKLE-JOINT.  271 


ture,  was  applied  so  as  to  prevent  the  escape  of  any 
discharge  ;  and  to  seal  the  covering  more  securely, 
six  leeches  were  applied  at  a  small  distance  from 
the  inflamed  part :  the  wounds  bled  freely,  and 
afforded  ease. 

April  29th.  He  passed  a  good  night ;  heat  less- 
ened; free  from  thirst;  limb  easy  without  tension; 
and  the  inflammation  about  the  ankle  abated. 

April  30th.  A  quiet,  good  night;  and  every 
symptom  appeared  favourable. 

May  2nd.  The  pulse  had  regained  the  natural 
standard.  Upon  examining  the  ankle,  a  small  quan- 
tity of  pus  escaped  from  the  lower  part  of  the 
dressing.  Lint,  wetted  in  the  same  manner,  to  glue 
the  covering  securely,  was  used.  From  this  time 
my  visits  became  less  frequent.  The  tincture  wa& 
used  whenever  the  surface  of  the  cap  appeared  to 
lose  its  hold.  At  the  end  of  ten  weeks  he  was 
taken  from  his  bed  daily,  and  laid  upon  a  sofa. 
After  the  first  stage  of  symptoms,  healthy  actions 
were  established,  and  he  became  perfectly  healthy. 
Between  the  third  and  fourth  month  the  cap  or 
dressing  was  taken  from  the  ankle ;  the  wound  was 
completely  cicatrised;  a  small  abraded  surface  ap- 
peared over  the  cicatrix,  occasioned  by  incrustcd 
matter.  Simple  dressings  rendered  the  wound 
sound  and  well  in  a  few  days.  During  the  time  of 
the  curative  process  the  faetor  was  very  trifling. 
The  thickening  upon  the  wound  was  not  more  than 
might  have  been  expected  :  the  form  of  the  joint 
was  natural,  and  bore  the  appearance  of  being  per- 
fect. At  the  end  of  five  months  he  was  allowed  to 
go  on  crutches,  to  place  the  foot  on  the  ground,  and 
to  use  such  weight  or  pressure  as  his  feelings  could 
admit.  For  many  months  an  application  of  oil,  ob- 
tained from  the  joints  of  animals,  was  made  use  of 
night  and  morning,  for  an  hour  each  time,  by  fric- 


272  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


tion  ;  and  to  please  himself,  the  patient  plunged  his 
foot  and  ankle  in  the  paunch  of  an  ox.  With  these 
means  an  imperfect  motion  in  the  joint  was  recov- 
ered, and  within  twelve  months  he  could  walk  with- 
out a  stick;  he  pursued  his  occupation,  and  lived  to 
the  age  of  eighty-three.  The  last  ten  years  he 
was  able  to  walk  as  well  as  ever  he  could.  Mr 
Jefferson  will  be  able  to  confirm  this  statement. 

Since  the  case  of  Cutting,  I  have  uniformly,  in  a 
variety  of  compound  fractures,  followed  the  curative 
plan  of  treatment  by  the  first  intention.  Mr  George 
Lynn,  of  Woodbridge,  my  son-in-law,  a  deserving 
character  in  his  profession,  and  the  late  Launcelot 
Davie,  of  Bungay,  were  pupils  of  mine,  and  attended 
many  cases  with  me  of  a  very  formidable  nature, 
successfully  treated  by  the  same  means.  A  com- 
pound fracture  of  the  ihigh,  attended  with  consider- 
able comminution  of  the  bone,  occasioned  by  a 
wagon,  loaded  with  twenty-five  combs  of  barley, 
passing  over  it,  was  perfectly  restored  by  the  same 
treatment  within  six  months. 

I  have  the  honour  to  be. 
Your  very  much  obliged  and  faithful  servant, 

JYeedham  Market^  Robert  Abbott. 

SufolL 


COMPOUND  DISLOCATION   OF  THE  TIBIA  OUTWARDS. 

Mr  Ransome,  surgeon  at  Manchester,  obliged  me 
with  the  following  case  :  — 

Case  in  a  strumous  habit,  —  Dear  Friend  :  —  In 
reply  to  thy  letter,  requesting  to  know  the  result  of 
my  experience  in  cases  of  compound  dislocation  of 
the  ankle-joint,  I  have  great  pleasure  in  stating  the 


DISLOCATIONS   OF  THE  ANKLE-JOINT. 


273 


following  case,  which  has  recently  occurred.  I  lake 
the  liberty  of  briefly  describing  it,  as  there  were 
some  circumstances  connected  with  it  which  did  not 
afford  the  most  flattering  prospect. 

In  the  autumn  of  last  year,  a  female,  aged  about 
forty-five  years,  of  a  strumous  and  leucophlegmatlc 
habit,  having  a  troublesome  cough  and  occasional 
dyspnoea,  fell  from  a  high  stool,  and  pitching  upon 
the  left  foot,  caused  a  compound  dislocation  of  the 
ankle-joint.  The  foot  was  luxated  inwards,  the  ex- 
ternal malleolus  was  fractured,  a  lacerated  wound 
extended  half  round  the  joint  and  exposed  the  pro- 
truding portion  of  the  malleolus,  laying  the  cavity 
of  the  joint  so  open  as  freely  to  admit  the  finger, 
and  through  it  the  synovial  fluid  escaped.  1  remov- 
ed a  portion  of  detached  bone,  reduced  the  disloca- 
tion, and  brought  the  integuments  together  very 
slightly;  the  limb  was  laid  upon  the  side,  and  kept 
constantly  cool  with  the  saturnine  lotion  combined 
with  the  liq.  ammon.  acet.  A  small  opiate  and  a 
demulcent  mixture  were  given  at  intervals.  From 
the  constitution  of  my  patient  I  must  confess  I  fear- 
ed the  most  serious  consequences,  but  I  was  happily 
mistaken.  Little  inflammation  followed,  the  wound 
healed  without  a  copious  suppuration,  and  she  is  now 
perfectly  recovered,  and  walks  to  considerable  dis- 
tances. She  was  confined  in  a  very  small  room,  and 
in  a  part  of  the  town  not  very  famous  for  the  purity 
and  salubrity  of  its  atmosphere. 

Manchester,  I  am,  your's  respectfully, 

October  227id,  1818.  T.  A.  Ransome. 


35 


274 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS,  AND 
FRACTURE  OF  THE  THIGH. 

To  Mr  Chandler,  of  Canterbury,  Surgeon  to  the 
Kent  and  County  Hospitals,  I  am  obliged  for  the 
following  communication. 

Bengal  Street^  Canterbury, 
My  dear  Sir: — I  take  the  earliest  opportunity  of 
complying  with  your  request,  to  furnish  you  with 
the  result  of  my  observations  on  compound  disloca- 
tion of  the  ankle-joint. 

You  will  perhaps  think  it  singular,  that  this  divi- 
sion of  Kent,  which  our  hospital  practice  embraces, 
should  be  so  destitute  of  cases  of  this  nature,  that 
only  two  have  occuried,  either  in  my  private  prac- 
tice or  at  our  hospital,  or  to  my  coadjutor,  Mr  Fitch, 
during  the  last  fifteen  years;  and  as  these  are  the 
only  instances,  I  fear  it  would  be  deemed  presump- 
tuous in  me  to  form  an  opinion  upon  the  method  to 
be  adopted,  and  the  probable  termination  of  the 
generality  of  such  accidents.  The  favourable  result, 
however,  of  these  two  cases,  admitted  under  my 
care  in  the  Kent  and  County  Hospitals,  was  so  firmly 
impressed  on  my  memory,  as  to  confirm  unequivo* 
cally  the  precepts  you  early  inculcated,  to  save  the 
limb  if  possible  in  compound  dislocations  of  the 
ankle-joint.  In  accomplishing  so  desirable  a  point, 
the  advantages  obtained  in  a  country  hospital,  will,  I 
apprehend,  bear  a  great  proportion  in  the  scale  of 
success,  compared  with  the  circumstances  ol'  a  pa- 
tient placed  in  a  crowded  infirmary  of  a  large  manu- 
facturing town,  or  in  the  metropolis:  the  constitution 
will,  in  general,  be  less  impaired  by  excess,  poverty, 
and  other  evils;  whilst  purity  of  air  in  large  venti- 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  275 


lated  wards  will  materially  contribute  towards  re- 
covery, even  if  the  injury  to  the  joint  be  extensive  : 
we  consequently  can  be  permitted  to  take  greater 
latitude  with  our  curative  means  upon  an  injured 
joint,  relying  on  the  powers  of  nature,  without 
being  under  the  immediate  necessity  of  anticipating 
the  issue  resulting  from  unfavourable  habits,  and  in 
situations  inimical  to  disease. 

My  notes  furnish  me  only  with  the  brief  details  of 
one  case. 

Cases,  —  July,  1818.  A  bricklayer,  aged  thirty- 
six,  of  slender  make,  but  of  good  constitution  and 
of  sober  habits,  fell  from  a  height  of  between  thirty 
and  forty  feet  upon  loose  materials  for  building,  and 
alighting  upon  his  feet,  received  a  very  severe  shock, 
attended  with  comatos3  symptoms,  a  fracture  of  the 
right  thigh,  a  considerable  contusion  and  laceration 
of  the  left  ankle-joint,  accompanied  with  a  disloca- 
tion of  the  bones  inwards,  the  tibia  resting  upon  the 
inner  side  of  the  astragalus;  a  portion  of  the  lower 
extremity  of  that  bone  was  fractured  ;  the  fibula 
was  broken  about  three  inches  above  the  malleolus 
externus,  and  the  surrounding  ligaments  of  the  joint 
were  lacerated;  little  difficulty  was  found  in  reduc- 
ing the  dislocation,  and  in  replacing  the  fractured 
bones  ;  but  in  consequence  of  the  violent  injury  done 
to  the  joint,  a  question  arose  on  the  propriety  of 
amputation.  As  the  man  had  enjoyed  uninter- 
rupted health,  and  was  of  the  constitution  and 
habit  least  liable  to  the  attack  of  inflammatory  af- 
fection, I  ventured  to  give  him  a  chance  of  saving 
the  limb.  A  union  by  the  first  intention  of  the  ex- 
ternal wound,  as  far  as  practicable,  was  attempted, 
and  the  limb  was  laid  in  the  most  convenient,  yet 
relaxed  and  easy  posture.  Evaporating  lotions  were 
applied,  and  the  strictest  antiphlogistic  system  en- 
joined. 


276  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


Symptoms;  disposition  to  gangrene,  S^c,  —  Consid- 
erable inflammatory  symptoms  ensued,  with  a  co- 
pious discharge  of  synovial  fluid;  the  limb  and 
joint  were  niuch  swollen,  and  it  became  necessary 
to  vary  the  treatment  by  applying  warm  spirituous 
and  opiate  fomentations  and  poultices,  which  appear- 
ed more  genial  to  the  patient's  feeling,  and  were 
therefore  continued.  A  disposition  of  the  contused 
parts  to  gangrene  appearing,  muriatic  acid  was  add- 
ed to  the  cataplasm,  and  the  medicines  were  chang- 
ed according  to  the  eflect  produced  on  the  constitu- 
tion by  symptomatic  irritation  accruing  from  the  dis- 
charge. The  disposition  to  gangrene  ceased  soon 
after  the  application  of  the  muriatic  acid  :  from 
this  medicine  1  have  often  derived,  in  similar  cir- 
cumstances, great  advantage.  After  the  first  fort- 
night my  hopes  of  saving  the  limb  were  confirmed 
by  the  abatement  of  pain  and  swelling,  and  by  the 
mitigation  of  the  constitutional  symptoms,  the  colour 
of  the  discharge  improving,  with  less  synovia,  and 
granulations  arising  round  the  wound.  The  patient 
continued  gradually  to  improve  till  about  the  tenth 
week,  when  the  wound  was  nearly  healed.  This 
man  was  discharged  in  fourteen  weeks  quite  well, 
although  with  rather  an  unsightly  and  partially  stiff 
joint. 

The  other  case,  of  which  I  have  notes,  was  also 
a  compound  dislocation  of  the  ankle-joint,  but  with- 
out the  degree  of  injury  sustained  in  the  former: 
this  patient  was  also  discharged  cured. 

I  have  now  to  apologise  for  trespassing  on  your 
time,  in  the  attempt  to  give  you  the  details  of  cases 
that  might  have  been  interesting  if  not  so  carelessly 
drawn  up;  but  as  my  notes  were  only  penned  to 
furnish  me  with  hints  for  the  future,  from  the  dis- 
tance of  time  the  minutes  have  escaped  my  memory, 
and  [  doubt  that  they  are  too  inaccurate  and  too 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


277 


inconclusive  to  afford  you  any  information;  but  the 
occasion  serves  me  as  a  pretext  for  assuring  you  how 
much 

I  remain,  dear  Sir, 
Your  very  faithful  and  obh'ged  servant, 

W,  Chandler. 


Royal  JYavy  Hospital,  Plymouth  ; 
-     August  ]Mh,  1819. 

My  dear  Sir  ;  —  In  answer  to  your  letter  inquir- 
ing of  me  whether  I  had  had  any  cases  of  com- 
pound dislocation  of  the  ankle-joint,  with  their 
treatment  and  their  result,  I  beg  leave  to  acquaint 
you,  that  several  of  the  above  nature  have  fallen 
under  my  care  and  observation  during  the  eight 
years  I  served  as  assistant-surgeon,  and  tlie  six- 
teen years  I  have  been  the  first  surgeon  of  this  hos- 
pital ;  during  nearly  the  whole  of  which  period  the 
country  was  engaged  in  active  naval  warfare,  and, 
consequently,  this  hospital  was  in  the  constant  re- 
ceipt of  important  surgical  cases  ;  and  I  have  also 
witnessed  a  few  more  from  other  causes.  The  re- 
sult of  my  observations  has  been,  that  in  cases  of 
compound  dislocation  of  the  ankle-joint  there  is  not 
only  a  chance  of  saving  the  limb,  but  of  that  limb 
being  at  a  future  time  usefuL  The  dislocated  bones 
should  be  replaced  in  their  situation  with  as  little 
violence  and  injury  as  possible  to  the  surrounding 
parts;  and  should  any  difficulty  arise  in  returning 
the  bones,  from  the  smallness  of  the  wound,!  freely 
enlarge  it  with  a  scalpel.  After  they  are  replac- 
ed, I  lay  the  limb  perfectly  extended  on  very  soft 
cushions  of  lint  arranged  on  three  pillows,  the  centre 


278 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


one  reaching  the  length  of  the  leg,  the  upper  one 
crossing  under  the  ham  and  inl'erior  part  of  the 
tliioh,  and  the  lower  one  crossing  under  the  heel, 
having  previously  placed   on  these  pillows  a  hne 
sheet,  folded  so  often  that  when  its  edges  are  turned 
in,  it  may  protect  the  limb  from  the  pressure  of  the 
splints:   under  this  sheet  are  laid  several  slips  of 
calico,  about  eighteen  inches  long  and  three  broad. 
When  the  limb  is  thus  comfortably  placed,  taking 
care  to  fill  up  every  hollow  with  lint,  I  draw  the 
edges  of  the  lacerated  integuments  as  near  together 
as  they  can  be  brought  by  the  gentlest  means,  re- 
taining them  with  small  slips  of  adhesive  plaster, 
and  covering  this  with  pledgets  of  soft  lint;  this 
done,  1  direct  the  foot  to  be  kept  very  steady,  whilst 
I  ultimately  place  the  slips  of  calico,  already  de- 
scribed, over  the  whole  length  of  the  extremity, 
draw  up  the  edges  of  the  sheet,  and  apply  on  each 
side  of  the  leg,  outside  of  all,  a  very  broad  splint 
of  common  deal,  of  such  length  as  to  reach  at  least 
three  inches  below  the  foot,  and  as  far  above  the 
knee-joint ;  these  splints  are  well  covered  with  lint, 
and  then  so  secured  as  to  afford  support  (but  no 
pressure)  to  the  whole  of  the  leg  and  foot,  the 
breadth  of  the  splint  materially  contributing  to  the 
latter  purpose,  and  allowing  the  tape  to  pass  around 
the  limb  without  injury.    The  foot  ought  also  to  be 
prevented  from  diopping,  or  altering  in  the  least 
degree  its  position,  by  passing  a  broad  tape  through 
a  hole  in  the  lower  ends  of  the  splints,  which  tape 
is  to  be  tied,  securing  between  the  sole  of  the  foot, 
which  will  effectually  keep  it  up,  and  securing  it 
further  by  a  stirrup  bandage;  when  every  thing  is 
thus  accomplished,  the  foot  and  leg  are  directed  to 
be  kept  constantly  wet  with  cold  water,  taking  care 
not  to  sponge  it  immediately  over  the  wound.  The 
subsequent  treatment  of  the  patient  must  depend 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


279 


upon  the  symptoms  which  arise.    This  is  the  plan 
I  pursue  in  those  cases  where  there  is  a  probability 
of  saving  the  limb.    I  have  seen  more  than  one 
case,  where,  after  great  perseverance  and  risk,  the 
limb  has  been  saved,  but  when  the  wounds  were  all 
healed,  has  been  found  of  little  or  no  use;  for  ex- 
ample, a  man  who  had  had  a  compound  dislocation 
of  the  ankle  in  the  West  Indies,  from  whence  he 
was  sent  to  England  as  an.  invalid,  became  my  pa- 
tient in  this  hospital,  and  when  received,  after  the 
lapse  of  thirteen  months  from  the  accident,  had  the 
whole  of  the  lower  head  of  the  tibia  (although  in 
its  proper  situation)  exposed,  black,  and  carious, 
which  at  the  end  of  a  year  and  a  half  came  away, 
more  than  three  inches  in  length  ;  and  at  the  expir- 
ation of  three  years  and  a  half  from  the  injury,  he 
quitted  the  hospital,  with  the  wound  healed,  but 
with  a  shortened,   deformed,  and   anchylosed  leg, 
liable  to  break  out  on  the  slightest  injury.  The 
great  question  to  be  decided,  however,  in  these  ac- 
cidents is,  in  what  cases  the  surgeon  is  justified  in 
attempting  to  save  the  limb,  and  in  what  cases  im^ 
mediate  amputation  is  necessary.    From  all  I  have 
seen,  I  should  not  hesitate  to  advise  the  immediate 
removal  of  the  limb,  where  the  lower  heads  of  the 
tibia  and  fibula  are  very  much  shattered;  where, 
together  with  the  compound  dislocation  of  these 
bones,  some  of  the  tarsal  bones  are  displaced  and 
injured;  where  any  large  vessels  are  divided,  and 
cannot  be  secured  without  extensive  enlargement 
of  the  wound  and  disturbance  of  the  sol't  parts; 
where  the  common  integuments,  with  the  neigh- 
bouring tendons  and  muscles,  are  considerably  torn  ; 
where  the  protruded  tibia  cannot  by  any  means  be 
reduced ;  and  where  the  constitution  of  the  patient, 
being  enfeebled  at  the  time  of  the  accident,  is  not 


280  DISLOCATIONS  OF  THE  ANKLE-JOINT. 

likelj  to  endure  pain,  discharge,  or  long  confine- 
ment. 

I  have  a  fine  specimen  of  injury  done  to  the  ti- 
bia, fibula,  and  tarsal  bones,  from  a  compound  dis- 
location, requiring  amputation  ten  months  after  the 
accident,  which  occurred  in  the  Mediterranean;  it 
is  very  much  at  your  service  to  see  or  copy,  but  I 
must  beg  of  you  to  have  the  goodness  to  return  it, 
as  it  belongs  to  a  collection  of  bones  which  I  have 
been  forming  for  the  last  twenty  years.  (See  Plate?) 
I  am  your's,  etc., 

Stephen  L.  Hammick. 

I  beg  Mr  Hammick  to  accept  my  thanks  for  his 
excellent  letter. 


The  following  case  shows  that  under  the  most 
unfavourable  circumstances,  these  injuries  are  not 
destructive  of  life,  in  persons  of  good  constitutions. 

Winchester,  August  Isi,  1819. 
My  dear  Sir :  —  In  answer  to  your  enquiries  con- 
cerning my  practice  in  compound  dislocations  of  the 
ankle-joint,  I  can  only  say,  that  in  almost  every  case 
that  I  have  witnessed,  the  general  injurj^  has  been 
so  great  as  to  require  amputation.  I  recollect  but 
one  case  in  which  amputation  was  not  necessary  ;  it 
was  that  of  a  patient  at  a  distance,  to  whom  I  was 
called  by  a  neighbouring  practitioner  about  five 
weeks  after  the  accident,  '  to  reduce  a  dislocation 
of  the  ankle,  as  he  had  reduced  the  fracture  of  the 
fibula.'  I  saw  the  patient,  but  the  fractured  fibula 
was  so  firmly  united,  that  a  reduction  could  not  be 
attempted  ;  the  compound  dislocation  gradually  got 
well,  if  you  can  call  the  greatest  deformity  I  ever 
saw,  well;  however,  no  bad  symptoms  arose,  and  I 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  281 


am  persuaded,  that  had  the  dislocation  been  at  first 
reduced,  the  case  would  have  terminated  in  a  most 
satisfactory  'manner. 

I  had  a  case  of  compound  fracture  of  the  elbow- 
joint,  in  the  person  of  Dr  Wool,  now  head  master 
of  Rugby,  which  did  well,  without  leaving  any  per- 
ceptible degree  of  stiffness. 

Your's  very  truly, 

W.  WiCKHAM* 


28,  Park  Street,  Bristol 
October  20th,  1818. 
My  dear  Sir  : — During  the  twenty-two  years  I 
have  been  surgeon  to  the  Bristol  Infirmary,  and  I 
believe  during  my  apprenticeship  there,  making  in 
all  nearly  thirty  years,  it  has  been  our  invariable 
practice  to  endeavour  to  save  the  limb  in  cases  of 
compound  dislocation  of  the  ankle,  unless  where  the 
chance  was  annihilated  by  some  concomitant  injuries 
or  circumstances ;  but  as  a  general  rule  it  was  al- 
ways adhered  to,  which  it  would  not  have  been  un- 
less the  great  majority  of  cases  had  done  well.  We 
save  the  limb  in  private  practice  almost  invariably, 
unless  in  very  bad  cases  indeed. 

I  am,  my  dear  Sir^ 

Your's,  etc. 
R.  Smith. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS. 

My  friend,  Mr  Fiske,  surgeon  at  Saffron  Walden, 
stated  to  me  the  following  case. 

Case,  —  A  man,  aged  sixty,  had  ascended  a  ladder 
to  a  considerable  height,  when,  accidentally  slipping, 
36 


282 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


he  fell  to  the  ground.  Mr  Fiske  being  called  to 
him,  found  the  tibia  dislocated  inwards  at  the  ankle- 
joint,  and  the  end  of  the  bone,  covered  by  its  carti- 
lage, protruding  tlirough  the  integuments.  He  im- 
mediately replaced  the  bone,  brought  the  integu- 
ments together  by  adhesive  plaster,  applied  a  ban- 
dage over  the  joint,  and  splints  upon  the  limb,  direct- 
ing him  to  remain  as  quiet  as  possible.  The  wound 
healed  without  any  untoward  circumstance,  and  the 
man  not  only  recovered,  but  has  the  advantage  of  an 
extremely  useful  limb. 


COMPOUND-  DISLOCATION  OF    THE  TIBIA  FORWARDS  AND 
TWO  CASES   OF  THE  TIBIA  OUTWARDS. 

I  have  received  the  following  cases  of  injury  to 
the  ankle  from  Mr  Maddocks. 

Cases,  —  Dear  Sir  :  —  These  cases  are  of  recent 
date,  and  I  have  a  perfect  recollection  of  every  im- 
portant circumstance  connected  with  them.  The 
first  happened  to  a  stout  healthy  young  man,  who, 
by  a  fall  from  a  vicious  horse,  dislocated  his  ankle. 
The  accident  happened  a  few  miles  from  Notting- 
ham. He  was  immediately  brought  to  his  master's 
house,  where  I  saw  him,  and  found  the  end  of  the 
tibia  protruding  through  a  large  lacerated  and  con- 
tused wound,  on  the  lore  part  of  the  ankle.  The 
fibula  was  broken  about  four  inches  ahove  the  joint, 
and  its  lower  end  was  separated  from  its  connexion 
with  the  tibia,  by  a  laceration  of  the  ligament  con- 
necting it  with  that  bone,  but  it  did  not  protrude. 
Appearances  in  many  respects  were  unfavourable,  as 
there  was  much  ligamentary  and  some  tendinous 
laceration  ;  but  as  the  tibia  was  sound,  and  the  fibula 
only  transversely  fractured,  I  was  encouraged  by  the 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


283 


resources  of  a  good  constitution,  and  more  particu- 
larly by  the  sanction  of  my  friend,  Mr  Wright,  a 
practitioner  of  much  experience,  to  attempt  the  pre- 
servation of  the  joint.  The  bones  wore  reduced 
with  little  difficulty,  and  the  limb  was  placed  in  a 
flexed  position  on  ils  side  on  a  broad  hollow  splint  ; 
the  supervening  symptoms  were  more  favourable 
than  could  have  been  expected  frouj  the  nature  of 
the  accident,  though  some  portion  of  the  integuments 
sloughed  away,  and  two  ditrercnt  suppuratiofis  took 
place  in  the  joint,  followed  by  two  small  exfoliations. 
The  patient  in  three  months  recovered  the  use  of 
the  joifit,  and  at  this  time  experiences  no  inconve- 
nience from  the  accident. 

External  dislocation,  S^^c.  —  Two  cases  of  external 
dislocation  occurred  in  boys,  both  of  whom  were 
healthy,  and  the  accidents  were  occasioned  by  falls 
from  horses;  the  malleoli  inteini  were  in  both  in- 
stances broken  off,  and  the  tibia  and  fibula  protruded 
two  or  three  inches  through  the  integuments.  In 
one  case,  the  projecting  end  of  the  fibula  was  left, 
adheriiig  by  its  ligament  to  the  anterior  part  of  the 
astragalus;  in  the  other  it  was  whole.  1  removed 
the  loose  portion  of  the  fibula,  the  bones  easily  united, 
and  the  limbs  were  placed  in  an  extended  position, 
supported  by  long  splints.  In  both  cases  the  inflam- 
mation was  high.  In  one,  a  large  abscess  formed, 
about  the  middle  of  the  leg.  and  a  discharge  of  mat- 
ter from  the  joint  continued  for  some  weeks,  attend- 
ed with  a  separation  of  sloughing  ligamentous  and 
membranous  parts,  The  wound  gradually  healed, 
the  discharge  abated,  and  the  boy  recovered,  with 
very  little  impediment  to  the  free  motion  of  the 
joint.  I^he  other  boy  would  have  been  equally  for^ 
tunate,  but  exfoliations  took  place  on  the  end  of  the 
tibia,  which,  though  small,  retarded  his  recovery  for 
several  weeks,  and  left  the  joint  less  perfectj^in  its 


284  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


motion  than  in  the  preceding  case,  but  quite  sufficient 
for  the  common  occupations  of  life.  You  have  here 
a  plain  statement  of  facts,  without  comment  or  em- 
belh'shment.  My  mode  of  treatment  has  been  uni- 
formly to  keep  the  limb  in  the  most  quiescent  state, 
and  to  meet  symptoms  as  they  arise  ;  and  I  cannot 
but  attribute  the  success  which  attended  the  treat' 
ment  of  these  cases  in  a  great  measure  to  that  pre- 
caution. 

I  am,  dear  Sir, 

With  great  respect,  your's, 

B.  Maddocks, 


DISLOCATION  OP  THE  TIBIA  AND   FIBULA  OUTWARDS, 

Sir: —  Not  having  the  honour  of  being  personally 
known  to  you,  I  trust  that  the  wish  you  have  ex- 
pressed in  your  work  on  dislocations  to  be  informed  of 
the  treatment  and  result  of  accidents  of  that  nature, 
will  plead  my  excuse  for  troubling  you  with  the  fol- 
lowing case  of  compound  dislocation  of  the  ankle. 

Case.  — On  the  22nd  of  October  last,  1  was  called 
upon  to  attend  Thomas  Saxty,  a  lad  about  thirteen 
years  of  age,  whose  left  foot  had  got  entangled  in  a 
strap  of  the  machinery  used  in  the  clothing  business. 
On  examination,  I  found  a  very  bad  compound  dislo- 
cation of  the  tibia  and  fibula  outwards  ;  the  bones 
were  protruding  four  or  five  inches  through  the  in- 
teguments, which  were  dreadfully  lacerated;  the 
wound  extended  from  the  external  malleolus  in  an 
oblique  direction  to  the  posterior  part  of  the  tibia, 
and  within  five  inches  of  the  head  of  that  bone,  which 
articulates  with  the  femur.  On  putting  my  fingers 
into  the  cavity  of  the  ankle-joint,  1  found  the  astra- 
galus very  loose,  being  torn  from  its  connecting  liga- 
ments. 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


285 


On  the  first  view  of  so  serious  an  accident,  I 
thought  it  would  be  impossible,  with  safety  to  my 
patient,  to  save  the  limb;  but  as  he  had  received  so 
severe  a  shock,  the  countenance  being  pale,  and  the 
extremities  cold,  I  determined  to  defer  the  amputa-* 
tion  until  the  constitution  should  be  recovered  from 
the  first  impression  of  the  accident,  and  proceeded 
in  reducing  the  limb  to  its  proper  situation,  which 
I  accomphshed  with  but  little  difficulty;  I  applied 
lint  to  the  wound,  and  covered  the  limb  with  a  many^ 
tailed  bandage  lightly  bound  on;  still  I  had  no  idea 
but  that  amputation  must  take  place,  and  the  next 
morning  1  requested  Mr  Carey,  a  very  intelligent 
surgeon  of  this  town,  to  assist  me  in  the  operation: 
owing  to  professional  engagements  he  could  not  ac^ 
company  me  to  the  boy  before  six  in  the  evening, 
Avhen,  on  examining  the  limb,  there  was  considerable 
inflammation  in  the  leg  above  the  lacerated  parts, 
and  gi'eat  tenderness  in  the  thigh,  which  1  then 
learnt  had  received  some  injury  at  the  time  of  the 
accident.  Under  these  circumstances  it  was  deter^ 
mined  to  delay  the  operation  for  the  present.  The 
limb  was  wrapped  in  a  warm  poultice  of  oatmeal 
and  yest,  the  boy  placed  on  his  left  side  with  the 
limb  in  the  bent  position,  and  a  draught  with  twenty 
drops  of  laudanum  ordered  to  be  taken  immediately: 
he  passed  a  restless  night.  On  the  following  morning, 
October  24tli,  the  inflammation  of  the  leg  above  the 
injury  was  considerably  increased,  with  very  great 
tenderness  on  pressure;  and  the  wound  had  a  dry, 
dark,  sphacelated  appearance.  I  ordered  my  patient 
some  wine  and  an  opiate  at  bed-time:  he  passed  a 
more  comfortable  night,  and  the  next  morning  the 
appearance  of  the  wound  had  improved.  In  the 
course  of  the  26th,  a  distinct  line,  marking  the  ex--- 
tent  of  mortification,  could  be  traced. 


286 


DISLOCATIONS  OP   THE  ANKLE-JOINT. 


It  would  be  useless  to  record  the  dally  progress  of 
the  case,  as  the  detail  would  take  up  too  much  of 
your  valuable  time;  suffice  it  to  say,  that  in  the 
course  of  three  weeks  the  whole  of  the  sphacelated 
parts  had  separated,  leaving  a  most  extensive  wound. 
The  poultices  were  now  laid  aside,  and  simple  dress- 
ings substituted  ;  a  many-tailed  bandage  was  applied 
to  give  suj:)port  to  the  limb,  and  a  splint  attached  on 
each  side  the  leg.  The  discharge  about  this  time,  a 
month  after  the  accident,  was  very  considerable;  but 
the  boy  having  a  good  constitution,  I  began  to  think 
there  might  be  some  chance  of  saving  the  limb,  and 
I  determined  not  to  amputate  unless  the  symptoms 
should  imperiously  demand  that  operation.  About 
four  inches  of  the  inferior  extremity  of  the  fibula 
Avere  expospd  to  view,  and  would  evidently  ex- 
foliate. 

On  November  2tUh,  I  placed  the  boy  on  his  back, 
the  limb  restin":  on  the  heel.  I  was  induced  to 
make  this  alteration  in  his  position  because  my  pa- 
tient had  experienced  considerable  pain  every  time 
the  limb  was  dressed,  as  it  was  obliged  to  be  moved 
daily  for  that  purpose. 

The  wound  at  this  time  did  not  go  on  so  well  as 
could  be  wished:  it  had  an  unhealthy  appearance, 
with  large,  flabby,  and  shining  granulations.  I  tried 
the  effects  of  stimulants,  such  as  a  weak  solution  of 
nitrate  of  silver,  a  solution  of  vitriolated  zinc,  etc., 
but  still  without  decided  benefit. 

On  November  the  30th,  nearly  six  weeks  from 
the  time  of  (he  accident,  that  part  of  the  fibula 
wliich  forms  the  external  malleolus  exfoliated;  and 
three  days  afterwards  I  succeeded  in  bringing  away  a 
broad  portion  of  the  articulating  surface  of  the  tibia. 
In  a  few  days  the  discharge  lessened,  but  there 
seemed  no  disposition  in  the  wound  to  heal. 

I  had  repeatedly  witnessed  the  good  eflects  of 


msLOCATiONS  OP   THE   ANKLE-JOINT.  287 

the  adhesive  plaster  in  ulcers  of  the  leg,  in  the 
manner  recom mended  by  the  late  Mr  Baynlon  ;  and^ 
as  in  the  present  case,  a  stimulant  was  required,  as  well 
as  support  to  the  edges  of  the  wound,  I  considered 
that  this  dressing,  applied  in  the  form  of  a  raany- 
tailcd  bandage  from  the  ankle  to  within  four  inches 
of  the  knee  (the  extent  of  the  wound),  would  in  all 
probability  amend  its  condition  and  appearances.  I 
was  not  disappointed;  lor  in  the  course  of  a  few 
days  after  the  application  of  the  plaster  the  wound 
began  to  heal  ;  and  from  that  time  to  the  present 
the  rapidity  of  the  cure  has  been  beyond  my  most 
sanguine  expectations. 

The  boy  is  now,  ^fteen  weeks  from  the  time 
when  he  received  the  injury,  able  to  walk,  with  the 
assistance  of  crutches,  to  the  factory,  a  distance  of 
half  a  mile  from  his  house.  To-day  I  observed 
tiiat  he  could  put  the  foot  flat  on  the  ground,  and 
walk  across  the  room  without  the  assistance  of  a 
stick. 

For  the  last  two  months  I  have  daily  given  pass- 
ive motion  to  the  ankle-joint;  but  I  fear,  from  the 
great  extent  of  injury,  that  he  will  never  recover 
the  perfect  use  of  it,  though  it  is  not  so  completely 
anchylosed  as  to  prevent  all  motion. 

It  appears  wonderful,  that  in  such  a  very  exten- 
sive laceration,  no  artery  requiring  a  ligature  should 
have  been  wounded. 

I  do  not  claim  to  myself  the  merit  of  having  sav- 
ed the  boy's  limb,  as  you  will  perceive  by  the  pre- 
ceding statement,  that  he  is  more  indebted  to  a 
fortuitous  circumstance.  At  the  time  when  my 
friend,  Mr  Carey,  saw  it,  there  was  too  much  inflam- 
mation above  the  seat  of  the  injury  to  warrant  us 
in  amputating. 

I  have  sent  you  the  portions  of  bone  that  have 
exfoliated,  as  I  thought  they  would  give  you  a  clear- 


288  DISLOCATIONS  OP  THE  ANKLE-JOtNT* 


er  idea  of  the  extent  of  the  injury  to  the  joint  than 
could  be  afforded  in  writing. 

I  recollect  about  nine  years  ago,  av hen  I  was  with 
my  father  at  Wantage,  the  occurrence  of  compound 
dislocation  of  the  ankle  inwards,  in  a  woman  about 
fil'ty  years  of  age  and  of  spare  habit ;  it  was  attend- 
ed with  but  little  laceration,  was  easily  reduced,  and 
eventually  the  patient  recovered,  but  with  a  com- 
plete anchylosis  of  the  joint. 

Should  any  circumstance  occur  during  the  further 
progress  of  the  cure  which  1  should  think  worth 
communicating  to  you,  I  will  take  the  liberty  of 
again  addressing  you ;  or  should  I  have  omitted  any 
thing  in  the  preceding  statement  which  you  consider 
of  consequence,  I  shall  be  very  happy  in  giving  you 
any  further  information  in  my  power. 

1  remain, 
Your  obedient,  humble  servant, 

Trowbridge^  Feb,  bth,  1822.  J.  Ormond. 


REMOVING  THE  ENDS  OF  THE  BONES. 

Sawing  off  the  ends  of  the  bones,  S{c,  —  There 
is  another  mode  of  treatment  in  these  accidents, 
which  consists  in  sawing  off  the  extremity  of  the 
tibia  before  the  bone  is  returned  into  its  natural 
situation  ;  and  the  reasons  which  may  be  assigned 
for  pursuing  this  practice  are  as  follow. 

Difficult  reduction.-^  First,  That  there  is  in 
some  cases  much  difficulty  in  the  reduction  of  the 
tibia,  and  great  violence  must  be  employed  to  ef- 
fect it. 

Oblique  fracture,  —  Secondly.  The  extremity  of 
the  bone  is  often  broken  obliquely,  so  that  when 
reduced  it  will  not  remain  upon  the  astragalus,  but 


DISLOCATIONS   OF  THE  ANKLE-JOINT.  289 


when  the  point  is  removed  by  the  saw,  it  rests  with- 
out difficulty  upon  that  bone. 

Spasms.  —  Thirdly.  The  spasmodic  contractions 
of  the  muscles  are  much  diminished  by  shortening 
the  bone,  as  it  throws  them  all  into  a  state  of  relax- 
ation ;  whereas,  if  the  bone  be  reduced  by  violence 
when  the  saw  has  not  been  used,  the  spasm  of  the 
limb  will  be  sometimes  very  violent. 

Local  irritation  diminished,  —  Fourthly.  The 
local  irritation  is  much  diminished  by  the  greater 
ease  with  which  adhesion  is  produced  of  the  sawn 
extremity  of  the  bone  to  the  parts  to  which  it  is 
applied ;  for  it  is  a  mistake  to  suppose  that  the 
sawn  end  of  the  bone -will  not  adhere;  the  contrary 
is  seen  in  amputation  in  sawing  off  a  bone  in  exostosis, 
and  in  the  union  by  adhesion  of  compound  fractures; 
and  that  adhesive  matter  can  be  thrown  out  upon 
cartilaginous  surfaces  is  known  to  every  person  who 
has  dissected  a  diseased  joint ;  it  is  thus  that  the 
end  of  the  tibia  adheres  to  the  surface  of  the  astra- 
galus. 

Suppuration  and  ulceration  lessened.  —  Fifthly. 
When  suppuration  does  occur  it  is  much  diminished, 
and  a  considerable  part  of  the  ulcerative  process  is 
prevented  by  the  mechanical  removal  of  the  carti- 
lage ;  for  nearly  half  the  articular  surface  of  the 
joint  no  longer  remains.  Caeteris  paribus,  therefore 
the  case  recovers  more  rapidly. 

Less  constitutional  irritation.  —  Sixthly.  The  con- 
stitutional irritation  is  very  much  lessened  by  the 
diminution  of  the  suppurative  and  ulcerative  pro- 
cess, and  by  the  ease  with  which  the  parts  are  re- 
stored. In  the  cases  which  I  have  had  an  opportu- 
nity of  seeing,  there  was  not  more  irritative  fever 
than  in  the  mildest  cases  of  compound  fracture. 

Bone  shattered.  —  Seventhly.  It  has  been  found 
that  in  cases  in  which  the  extremities  of  the  bones 
37 


290 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


forming  the  joint  have  been  broken  into  small  pieces, 
and  in  which  these  have  been  removed  by  the  finger, 
the  patient  has  suffered  less,  and  has  more  quickly 
recovered,  than  when  the  bone  has  been  returned 
whole. 

JVo  case  of  death.  —  Eighthly.  I  have  known  no 
case  of  death  when  the  extremities  of  the  bones 
have  been  sawn  off,  although  I  shall  have  occasion 
to  mention  some  in  which  the  cases  terminated  fa- 
tally when  this  was  not  done. 

Objections;  limb  shorter.  —  The  objections  which 
may  be  made  to  this  mode  of  treatment  are,  that 
the  limb  becomes  somewhat  shorter  by  the  removal 
of  the  cartilaginous  extremity  of  the  bone  ;  but  this 
I  do  not  think  an  objection  of  any  considerable  weight, 
if  the  danger  of  the  case  be,  as  I  believe,  lessened 
by  it ;  for  the  diminished  length,  which  is  very  slight, 
is  easily  supplied  by  a  shoe  made  a  little  thicker 
than  usual. 

Anchylosis.  —  The  other  objection  is,  that  the 
joint  becomes  necessarily  anchylosed.  I  doubt  very 
much  the  reality  of  this  objection,  as  in  two  instances 
I  have  seen  the  motion  of  the  part  remain;  but 
even  when  the  joint  becomes  anchylosed,  a  conse- 
quence to  which  it  is  liable  in  either  mode  of  treat- 
ment, the  motion  of  the  tarsal  bones  becomes  so 
much  increased  as  to  compensate  for  that  of  the 
ankle,  the  patient  walks  with  much  less  halting 
than  would  be  anticipated,  and  has  a  very  useful 
limb. 

Each  mode  useful.  —  My  intention,  however,  is  not 
to  advocate  either  mode  of  treatment  to  the  exclu- 
sion of  the  other,  but  to  state  the  reasons  which 
may  be  justly  assigned  for  the  occasional  adoption  of 
either.  It  is  only  by  a  comparison  of  the  different 
results  of  varied  practice  that  a  safe  conclusion  can 
be  drawn  ;  and  from  what  I  have  had  an  opportu- 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


291 


nity  of  observing  in  my  own  practice,  and  of  learning 
from  that  of  my  friends,  I  feel  disposed  to  recom- 
mend to  those  whose  minds  are  not  settled  upon  the 
subject,  not  hastily  to  determine  against  either  treat- 
ment in  the  different  cases  of  this  injury,  as  from 
each  mode,  under  varied  circumstances,  a  strong  and 
useful  limb  has  been  saved  without  any  additional 
risk  to  the  life  of  the  patient. 

Cases  in  which  the  one  or  the  other  should  be  em- 
ployed, —  [f  the  dislocation  can  be  easily  reduced 
without  sawing  off  the  end  of  the  bone  ;  if  the  bone 
be  not  so  obliquely  broken,  but  remain  firmly  placed 
upon  the  astragalus  when  reduced;  if  the  end  of  the 
bone  be  not  shattered,  for  then  the  small  loose  pie- 
ces of  bone  should  be  removed,  and  the  surface  of 
the  bone  be  smoothed  by  the  saw;  if  the  patient  be 
not  excessively  irritable,  so  as  to  occasion  the  mus- 
cles to  be  thrown  into  violent  spasmodic  actions  in 
the  attempt  at  reduction,  which  leads  to  subsequent 
displacement  when  the  limb  has  been  reduced ;  the 
bones  should  be  at  once  returned  into  their  places, 
and  the  parts  should  be  united  by  the  adhesive  in- 
flammation ;  but  rather  than  amputate  the  limb,  if 
the  above  circumstances  were  present,  I  should  cer- 
tainly saw  off  the  ends  of  the  bones. 

I  shall  now  proceed  to  state  the  cases  which  I 
have  myself  had  an  opportunity  of  witnessing,  and 
some  which  have  been  furnished  by  my  friends,  and 
shall  leave  the  reader  to  judge  of  the  propriety  of 
the  advice  I  have  given. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  OUTWARDS  AT 
THE  ANKLE-JOINT, 

Case,  —  I  was  sent  for  to  Guy's  Hospital,  to  see 
Nathaniel  Taylor,  aged  thirteen  years,  and  was  di- 


292  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


reeled  to  bring  my  amputating  instruments  with  me, 
being  informed  that  the  boy  had  so  bad  a  dislocation 
of  the  ankle  that  the  limb  could  not  be  saved. 

Appearances  ;  removal  of  the  end  of  the  fibula^  ^c. — 
As  soon  as  I  arrived  at  the  hospital,  I  ordered  the 
patient  into  the  operating  theatre  ;  and  making  in- 
quiries into  the  cause  and  nature  of  the  accident,  I 
found  the  particulars  to  be  as  follows:  The  injury 
had  been  occasioned  by  a  boat  falling  upon  the  leg. 
A  large  wound  appeared  at  the  outer  ankle,  through 
which  the  tibia  and  a  fractured  extremity  of  the 
fibula  projected  ;  one  inch  of  the  malleolus  externus 
remained  attached  to  the  astragalus  by  its  natural 
hgaments;  the  foot  was  turned  inwards  so  as  to  be 
capable  of  being  brought  in  contact  wnth  the  inner 
side  of  the  leg ;  and  as  the  muscles  were  no  longer 
on  the  stretch  the  foot  was  very  loose  and  pendu- 
lous. I  tried  to  reduce  the  limb,  but  found  that  the 
bone  could  only  by  great  violence  be  brought  on  the 
astragalus,  and  that  it  immediately  slipped  from  its 
place.  The  case  was,  therefore,  as  regarded  the 
state  of  the  parts,  the  most  unfavourable  possible, 
and  those  around  me  urged  an  immediate  amputa- 
tion;  but  seeing  the  character  of  health  which  the 
boy  bore,  I  thought  I  should  not  be  justified  in  pro- 
bably dooming  him  to  a  life  of  mendicity,  and  I  de- 
termined to  try  to  preserve  the  limb.  Finding  that 
the  lower  end  of  the  fibula,  although  still  connected 
by  ligament,  was  very  loose  and  moveable,  I  sepa- 
rated it  with  a  scalpel;  I  then  sawed  off  half  an 
inch  of  the  lower  extremity  of  the  tibia.  When 
these  operations  had  been  accomplished  with  the 
greatest  care,  I  reduced  the  bones,  and  they  main- 
tained their  situation,  as  there  was  no  force  of  mus- 
cular action  upon  them,  on  account  of  the  shortening 
ef  the  bones.  L»int,  dipped  in  the  patient's  blood, 
was  then  applied, with  adhesive  plaster  over  it;  and 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


293 


the  leg  was  put  in  splints,  and  placed  on  the  heel. 
Scarcely  any  constitutional  irritation  occurred  ;  the 
wound  and  ankle-joint  secreted  but  little  matter,  and 
gradually  healed.  On  the  seventeenth  day  an  jib- 
scess  showed  itself  on  the  tibia,  which  was  suffered 
to  burst,  as  it  had  little  affected  his  constitution.  In 
two  months  he  was  allowed  to  sit  up  and  use  his 
crutches.  In  twelve  weeks  the  wound  was  healed, 
and  the  boy  was  able  to  bear  on  his  foot;  and  at  the 
end  of  four  months  he  walked  Well.  I  experienced 
inconceivable  pleasure  in  seeing  this  boy  walk  before 
the  students,  at  my  desire,  from  one  end  of  the  ward 
to  the  other,  four  months  after  the  accident,  with 
very  little  lameness.  There  seemed  to  be  some 
motion  at  the  ankle,  but  the  tarsal  bones  soon  ac- 
quired sufficient  mobility  to  give  to  the  foot  so  much 
play  as  to  prevent  the  appearance  of  stiffness,  which 
a  partially  anchylosed  state  of  the  ankle  would 
otherwise  have  produced. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS. 

Case,  West,  Esq,  aged  forty,  on  Decem- 
ber 11th,  1818,  jumped  out  of  his  one-horse  chaise, 
alarmed  by  the  horse  kicking.  He  fell,  and  when 
he  attempted  to  rise,  found  his  left  ankle  dislocated, 
and  the  bone  projecting  through  the  skin.  Mr 
Mackinder,  surgeon,  brought  him  to  the  house  of 
his  father-in-law,  in  London,  where  Mr  Jones,  of 
Mount-street,  and  myself  attended  him. 

Integuments  pressed  between  the  bones.  —  Upon  ex- 
amination of  the  part,  I  found  the  tibia  projecting 
at  the  inner  ankle  through  the  integuments,  which 
were  nipped  under  the  projecting  bone  into  the 
joint:  the  foot  was  loose  and  pendulous,  and  very 


294 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


much  thrown  outwards.  Having  prepared  several 
pieces  of  linen  to  form  a  manj-tailed  bandage,  and 
procured  pillows  and  splints,  the  patient  was  placed 
ort  a  bed  on  his  left  side,  and  an  attempt  was 
made  to  reduce  the  bone  ;  but  hearing  from  Mr 
Jones  that  Mr  W.  was  of  a  most  irritable  constitu- 
tion, and  finding  that  most  powerful  extension  must 
be  made,  and  that  the  integuments  must  be  divided 
opposite  to  the  joint,  so  as  to  lessen  the  probability 
of  an  easy  adhesion  to  the  wound,  which  was  placed 
one  inch  and  a  half  above  the  articulation,  1  sawed 
off  the  end  of  the  tibia,  and  the  bone  most  easily 
returned  into  its  natural  situation,  in  which  it  re- 
mained without  difficulty.  The  edges  of  the  wound 
were  brought  together  by  a  fine  thread,  so  as  to  be 
very  closely  adapted  to  each  other ;  and  lint,  dipped 
in  blood,  was  applied  over  the  wound :  the  many- 
tailed  bandage  was  used :  the  limb  was  placed  on 
its  outer  side,  with  the  knee  bent  nearly  at  right 
angles  with  the  thigh,  and  splints  were  applied. 
The  leg  was  ordered  to  be  kept  constantly  wet  with 
the  liq.  plumbi,  s.  acetat.  dilutus,  3  v.  and  spir.  vini 
3i. ;  a  dose  of  opium  was  given  to  him,  and  ten 
ounces  of  blood  were  taken  from  his  arm.  In  the 
evening  more  opium  was  administered,  and  a  dose 
of  infusion  of  senna  and  sulphate  of  magnesia  was 
ordered  for  the  morning. 

December  12.  As  the  limb  felt  hot,  the  upper 
splint  was  removed,  its  pressure  being  somewhat 
painful,  and  preventing  free  evaporation.  Opium 
was  ordered  at  night. 

December  13.  The  foot  was  vesicated.  He  had 
chilliness  succeeded  by  heat ;  slight  tension  of  the 
leg,  and  some  pain  for  three  hours.  His  mind  was 
much  agitated  by  seeing  his  children. 

December  14.  The  limb  was  less  inflamed,  and 
he  had  scarcely  any  constitutional  irritation. 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  295 


December  15.  A  slight  discharge  of  serum  mixed 
with  red  particles  from  the  wound  ;  some  pain  in 
the  foot  and  leg, 'but  no  irritative  fever. 

December  16.  There  was  more  discharge,  and 
some  air  passed  from  the  wound;  a  poultice  was  ap- 
plied, and  a  generous  diet  allowed,  as  his  stomach, 
naturally  weak,  had  become  very  flatulent.  Pulse 
90. 

December  17.  A  fomentation  and  poultice  applied. 
Derangement  of  the  stomach.  —  December  18. 
The  discharge  was  becoming  purulent;  but  as  his 
stomach  was  deranged,  he  was  visited  by  Dr  Pem- 
berton,  who  ordered  him  hyoscyamus  with  the  mix- 
tura  camphor,  in  the  day,  and  opium  at  night. 

From  this  time  to  the  7th  of  January,  the  discharge 
from  the  limb  was  copious,  but  it  then  began  to 
lessen;  and  when  the  leg  was  examined  on  the  12th 
of  January,  it  had  become  firm ;  a  small  wound  re- 
mained, on  which  the  granulations  were  prominent. 
In  the  first  week  in  February  he  was  allowed  to  get 
upon  his  sofa,  the  limb  being  now  firm,  and  only  a 
small  wound  remaining,  from  which  an  exfoliation 
will  occur,  as  the  bone  can  be  felt  bare. 

In  August  1  saw  him  ;  the  wound  still  remained 
open,  and  the  portion  of  bone  had  not  separated. 

This  gentleman,  with  the  worst  constitution  in  re- 
gard to  the  state  of  his  stomach,  did  not  suffer  so 
much  irritation  as  a  compound  fracture  usually  pro- 
duces. 


COMPOUND  DISLOCATION   OF  THE  TIBIA  INWARDS. 

Mr  Charles  Averill,  dresser  to  Mr  Forster,  Sur- 
geon of  Guy's  Hospital,  had  the  kindness  to  send  me 
the  following  particulars  of  a  case,  the  progress  of 
which  I  often  witnessed  with  pleasure. 


290 


DISLOCATIONS   OF  THE  ANKLE-JOINT. 


Case ;  use  of  nitric  acid,  Src.  —  John  Williams, 
sailor,  aged  thirty-eight,  a  very  robust  man,  was 
brought  into  Guy's  Hospital,  under  the  care  of  Mr 
Forster,  August  9th,  1819,  at  four  o'clock  in  the 
morning,  with  a  compound  dislocation  of  the  right 
ankle  inwards,  and  considerable  injury  to  the  left, 
occasioned  by  his  falling  from  a  height  of  about 
t  .venty-six  feet,  in  endeavouring  to  escape  from  the 
Borough  Compter,  in  which  he  was  imprisoned.  On 
examining  the  injured  part,  I  found  the  tibia  pro- 
truding three  inches  through  a  large  transverse 
wound  of  four  inches  in  extent,  and  resting  on  the 
inner  side  of  the  os  calcis ;  the  cartilaginous  surface 
of  the  astragalus  could  be  readily  felt  on  passing  my 
finger  into  the  w^ound  ;  the  fibula  was  broken.  I 
first  sawed  of!' the  whole  of  the  cartilaginous  end  of 
the  tibia,  when  the  bone  was  easily  replaced ;  the 
edges  of  the  wound  were  then  brought  as  much  in 
contact  as  possible  ;  lint  dipped  in  blood  was  applied, 
and  over  it  straps  of  adhesive  plaster ;  the  foot  and 
leg  were  wrapped  in  cloths  wet  with  a  lotion  of 
acetate  of  lead,  and  the  limb  was  laid  on  its  side. 
He  complained  of  great  pain  in  the  left  leg,  which 
was  very  much  swollen  all  around  the  ankle  ;  ten 
leeches  were  applied  to  it,  and  afterwards  the  liquor 
plumbi  subacetatis  dllutus,  which  relieved  the  pain; 
thirty  drops  of  laudanum  were  given,  and  he  re- 
mained easy.  On  the  following  day  sixteen  ounces 
of  blood  were  taken  from  him,  and  five  grains  of 
calomel  were  given.  On  the  12th,  the  dressings 
were  removed;  the  wound  looked  well.  On  the 
17th,  suppuration  had  commenced  ;  .and  the  discharge 
having  rather  a  foeted  smell,  the  nitric  acid  lotion 
was  applied.*    September  2nd,  the  matter  gravitat- 

*  The  nitric  acid  lotion,  during  the  sloughing  process,  is  the 
best  application  with  which  I  am  acquainted.  I  order  it  in  the 
proportion  of  fifty  drops  of  the  acid  to  a  quart  of  distilled  water, 
and  apply  it  by  linen  covered  with  oiled  silk.  —  A.  C. 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


297 


ing  to  the  outer  side  of  the  leg,  an  opening  was 
made,  by  which  it  was  discharged,  and  adhesive 
plaster  applied  to  the  original  wound,  which  was 
healing  fast;  the  discharge  gradually  diminished; 
and  on  the  21st  of  September,  six  weeks  from  the 
accident,  both  wounds  w^ere  quite  healed.  He  has 
not  yet  left  his  bed.  There  is  motion  at  the  ankle; 
the  toe  turns  out  but  very  little,  and  does  not  point 
downwards.  He  wears  splints,  and  the  strength  of 
the  limb  is  daily  increasing.  When  the  swelling  of 
the  left  ankle  diminished,  a  fracture  of  the  external 
malleolus  was  also  there  discovered. 

October  4th^  1819.  Charles  Averill. 

This  man  escaped  from  the  hospital  on  the  24th 
of  October,  was  retaken  two  months  afterwards, 
and  is  now  in  the  Borough  Compter.  He  has  free 
motion  of  the  right  ankle,  and  suffers  more  from  the 
injury  to  the  left. 

For  the  following  letter  I  am  indebted  to  Dr  Kerr, 
of  Northampton,  who,  at  the  age  of  more  than  eighty, 
still  continues  to  practice  his  profession  with  all  the 
ardour  of  youth,  and  with  a  strength  of  intellect 
which  has  been  seldom  surpassed. 

JVorthampton,  July  2nth,  1819. 
My  dear  Sir  :  —  I  have  had  the  honour  of  your 
letter  this  morning  respecting  compound  dislocation 
of  the  ankle ;  several  such  cases  have  fallen  under 
my  care,  and  it  has  been  uniformly  my  practice  to 
take  off  the  lower  extremity  of  the  tibia,  and  to  lay 
the  limb  in  a  state  of  semiflection  upon  splints;  by 
this  means  a  great  deal  of  painful  extension,  and 
the  consequent  high  degree  of  inflammation,  are  avoid- 
ed. The  splints  1  use  are  excavated  wood,  and  much 
wider  than  those  in  common  use,  with  thick  moveable 
38 


298  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


pads  stuff'ed  with  wooL  I  keep  the  parts  constantly 
wetted  with  a  solution  of  h'quor  ammonias  acetatis, 
without  removing  the  bandage.  In  my  very  early 
lil'e,  upwards  of  sixty  years  ago,  I  saw  many  attempts 
to  reduce  compound  dislocation  without  removing 
any  part  of  the  tibia  ;  but,  to.  the  best  of  my  re- 
collection, they  all  ended  unfavourably,  or,  at  least, 
in  amputation.  By  the  method  which  1  have  pursued, 
as  above  mentioned,  1  have  generally  succeeded  in 
saving  the  foot,  and  in  preserving  a  tolerable  articu- 
lation. 

I  am,  with  much  esteem,  my  dear  Sir, 
Your  obedient,  humble  servant, 

William  Kerr. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  OUTWARDS. 

To  Dr  Rumsey,  of  Araersham,  I  am  obliged  for 
the  following  interesting  communication. 

Amersham. 

Dear  Sir: — I  have  the  pleasure  of  forwarding 
to  you  the  case  of  a  compound  dislocation  of  the 
ankle,  which  came  under  my  care  many  years  ago, 
and  which  had  a  fortunate  termination,  as  the  pa- 
tient lived  many  years  after  the  accident. 

Case  ;  complicated  with  fracture  of  the  femur,  8^c» 
—  On  June  the  21st,  1702,  Mr  Tolson,  aged  forty 
years,  was  thrown  from  a  curricle  on  Gcrrard's- 
cross  Common,  eight  miles  from  this  place.  The 
injury  he  received  consisted  in  a  compound  disloca- 
tion of  the  tibia  and  fibula  at  the  outer  ankle  of  the 
left  leg,  with  a  fracture  of  the  astragalus  (the  supe- 
rior half  of  which  was  attached  to  the  dislocated 
bones  of  the  leg),  and  likewise  a  simple  fracture  of 
the  08  femoris  on  the  same  side.    He  was  conveyed 


DISLOCATIONS  OF  THE  ANKLE-JOINT, 


299 


to  a  friend's  house  on  the  Common,  where  he  had 
the  advantage  of  an  airy,  healthy  situation,  with 
every  kind  of  domestic  attention.  I  saw  him  about 
two  hours  after  the  accident,  and  found  the  bones 
protruding  at  the  ankle  through  a  very  large  wound, 
with  the  foot  turned  inwards  and  upwards,  and  the 
integuments  beneath  the  wound  exceedingly  confined 
by  the  dislocated  bones  which  descended  nearly  to 
the  bottom  of  the  foot.  A  considerable  haemorr- 
hage had  taken  place,  but  was  stopped  by  the 
spontaneous  contraction  of  the  lacerated  vessels. 

From  such  a  formidable  accident,  in  so  large  a 
joint,  there  appeared  very  little  probability  of  the 
patient's  recovery  without  immediate  amputation; 
I  therefore  requested  that  a  consultation  with  some 
other  surgeons  might  be  expeditiously  held  on  the 
case,  and  expresses  for  this  purpose  were  accord- 
ingly sent  to  Mr  Pearson,  surgeon  in  London,  and  to 
my  brother,  Mr  Henry  Rumsey,  surgeon  at  Ches- 
ham,  in  this  county.  While  1  was  waiting  for  their 
arrival,  the  patient  requested  me  to  examine  his 
thigh,  when  1  plainly  discovered  an  oblique  fracture 
of  the  OS  femoris  at  its  superior  part.  This  addi- 
tional evil  appeared  to  me  a  great  obstacle  to  an 
amputation.  My  brother,  when  he  arrived,  being  of 
a  similar  opinion,  I  attempted  to  reduce  the  fractur- 
ed dislocated  joint  mto  its  proper  situation.  This  I. 
found  very  difficult  without  first  separating  that  part 
of  the  astragalus  which  was  pendulous  to  the  tibia, 
having  its  capsular  ligament  lacerated  half  way 
around  the  joint.  This  portion  of  the  astragalus 
consists  of  the  broad  smooth  head  by  which  it  is 
articulated  to  the  tibia;  of  almost  the  whole  of  the 
inner  and  outer  sides  of  this  head,  by  which  it 
moves  on  the  inner  and  outer  malleoli;  and  of  about 
the  upper  half  of  the  posterior  cavity  on  its  under 
surface,  by  which  it  is  united  to  the  os  calcis ;  so 


300  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


that  the  bone  was  divided  nearly  horizontally,  and 
the  part  left  behind  consisted  of  the  lower  half  of 
the  last  mentioned  cavity,  of  the  whole  of  the  other 
or  anterior  cavity  which  connects  it  with  the  os 
calcis,  and  of  the  anterior  portion  or  process  by 
which  it  is  articulated  to  the  os  naviculare  :  1  there- 
fore removed  it  without  hesitation,  being  per- 
suaded that  if  it  had  been  practicable  to  reduce  it 
into  its  original  situation,  so  large  and  moveable  a 
portion  of  bone  would  have  been  a  source  of  pain 
and  irritation,  and  have  rendered  the  cure  more 
difficult  and  uncertain.  I  then  divided  that  portion 
of  the  integuments  of  the  foot  which  was  confined 
by  the  protruded  end  of  the  tibia,  and  was  thus 
enabled  with  ease  to  reduce  it  and  the  fibula  into 
their  proper  situation.  I  applied  some  dossils  of 
lint  dipped  in  tincture  of  opiuna  to  the  wound,  and 
covered  the  whole  with  a  poultice  of  stale  beer 
and  oatmeal.  We  now  reduced  the  fractured 
femur,  and  placed  the  limb  in  a  bent  position,  ex- 
pecting that  our  greatest  success  would  be  in  pro- 
curing a  complete  anchylosis,  the  failure  of  which  I 
concluded  would  leave  a  useless  foot.  The  under 
splint  was  a  firm  excavated  piece  of  deal,  of  the 
shape  of  the  leg  and  foot,  with  a  hole  opposite  the 
ankle.  Mr  Pearson  arrived  in  the  evening,  and  ap- 
proved of  tlic  preceding  treatment ;  giving  it  as  his 
opinion,  that  it  would  be  safer  to  attempt  the  pre- 
servation of  the  limb  than  to  amputate,  under  such 
complicated  circumstances.  The  wound  was  con- 
cealed as  much  as  possible  from  the  external  air, 
and  the  cataplasm  renewed  no  oftener  than  the  dis- 
charge rendered  necessary. 

June  22nd.  The  preceding  night  had  been  very 
painful,  with  delirium  and  vomiting;  the  pulse  was 
full  and  frequent ;  I  took  away  ten  ounces  of  blood, 
and  gave  potassse  tartras  and  manna  in  doses  suffi- 


DISLOCATIONS  OP  THE  ANKLE-JOINT.  301 


cient  to  procure  stools.  A  common  saline  draught, 
with  antimonial  wine  and  tincture  of  opium,  was 
given  every  four  hours,  and  a  fuller  dose  of  tincture 
of  opium  at  bed-time. 

23rd.  The  vomiting  continued  ;  the  ankle  and 
thigh  had  been  less  painful  through  the  night  ;  the 
saline  draughts  were  continued,  but  without  the  an- 
timony, on  account  of  the  vomiting;  during  this 
period,  the  antiphlogistic  regimen  was  strictly  ad- 
hered to. 

24th.  The  night  had  been  tolerable  ;  the  vomit- 
ing had  ceased;  the  pulse  was  softer;  the  saline 
draughts  were  continued,  with  the  opiate  at  bed- 
time ;  this  evening  the  leg  was  very  painful;  he 
passed  a  pretty  goodnight;  a  discharge  from  the 
wound  now  commenced,  and  the  tension  of  the 
muscles  of  the  thigh  began  to  diminish. 

26th  and  27th.  The  same  treatment  was  con- 
tinued. The  discharge  increased,  and  the  tension 
of  the  thigh  still  more  abated. 

28th.  The  ankle  was  much  swelled  and  inflam- 
ed; I  therefore  exchanged  the  beer  grounds  in  the 
cataplasm  for  the  liquor  plumbi  subacetatis  dilutus. 
The  patient  had  this  day  much  pain  in  the  bowels 
from  flatulence  ;  from  which  circumstance,  and  that 
of  the  discharge  being  very  thin,  it  was  judged  ex- 
pedient to  vary  his  mode  of  living,  and  likewise  his 
medicines. 

Change  of  diet  and  treatment,  Src  —  29th.  He 
was  allowed  a  small  portion  of  animal  food,  some 
table  beer,  and  some  port  wine  ;  and  he  took  the 
bark  liberally,  both  in  substance  and  in  decoction. 
This  change  of  treatment  agreed  with  him  perfect- 
ly well.  At  this  time  I  found  it  necessary  to  alter 
the  position  of  the  limb,  on  account  of  the  pressure 
on  the  wound,  occasioned  by  its  lying  in  the  bent 
position,  and  by  the  pain  caused  in  turning  to  dress 


302  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


it,  which,  from  the  copious  discharge,  now  required 
to  be  done  night  and  morning.  I  therefore  placed 
it  on  the  heel,  using  the  common  deal  flexible  splint, 
of  the  length  of  the  limb,  and  confined  it  in  a  box, 
whose  sides  and  lower  end  let  down ;  the  space 
between  the  sides  of  the  box  and  splint  was  filled 
with  pieces  of  flannel.  By  these  means,  and  the 
use  of  the  eighteen-tailcd  bandage,  the  dressings 
were  applied  with  very  little  disturbance  to  the  leg, 
and  thus  the  patient  escaped  much  pain.  The  up- 
per end  of  the  box  under  the  ham  being  raised, 
gave  the  muscles  some  degree  of  flexion,  and  at  the 
same  time  was  favourable  to  the  discharge.  The 
foot  having  a  tendency  to  fall  inward,  and  the  end 
of  the  fibula  to  protrude  through  the  wound,  it  re- 
quired great  attention  to  prevent  the  deformity 
which  the  neglect  of  these  circumstances  might 
have  occasioned.  The  mode  of  prevention  which 
I  adopted,  and  which  proved  successful,  consisted 
in  employing  a  number  of  small  deal  wedges,  about 
six  inches  long,  two  broad,  and  a  quarter  of  an  inch 
thick ;  as  many  of  these  as  were  found  sufficient 
were  placed  opposite  the  inside  of  the  foot,  between 
it  and  the  side  of  the  box:  others,  in  the  same 
manner,  were  placed  on  the  outer  side  of  the  calf 
of  the  leg;  by  which  means  the  limb  was  kept 
steady;  and  by  retaining  the  heel  in  an  easy  and 
rather  hollow  position,  none  of  the  usual  evils  aris- 
ing from  pressure  on  the  heel  occurred. 

30th.  The  bark  agreed  very  well ;  the  opiate 
was  continued  at  bed-time;  the  discharge  was  great 
but  more  purulent;  the  pulse  was  become  softer  and 
less  frequent ;  and  the  urine,  which  had  hitherto 
been  clear  and  very  high  coloured,  was  now  turbid; 
the  pain  and  inflammation  being  much  diminished, 
the  cataplasm  was  discontinued  ;  the  wound  was 
dressed  with  dry  lint,  with  a  pledget  of  cerat.  plumbi 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


303 


superacetatia  over  it,  and  a  moderate  compression 
was  made  by  means  of  a  bandage.  From  this  pe- 
riod the  wound  progressively  mended ;  the  discharge 
diminished;  granulations  formed;  and  the  surround- 
ing skin  began  to  heal.  The  use  of  the  bark  and 
of  the  opiate  was  continued  till  the  beginning  of 
August.  About  the  end  of  July,  the  progress  of 
the  cure  was  retarded  by  matter  collected  under  the 
integuments,  above  the  inner  ankle,  which  on  pres- 
sure came  out  at  the  wound.  After  in  vain  trying 
the  effects  of  permanent  pressure  for  the  prevention 
of  this  deposit,  I  made  an  incision  into  the  cavity 
and  filled  it  with  dry  lint,  to  produce  inflammation 
on  its  internal  surface,  which  consolidated  it,  and 
the  wound  became  perfectly  cicatrised  by  the  mid- 
dle of  September,  without  any  exfoliation  of  bone 
larger  than  the  head  of  a  pin  having  taken  place. 
The  fracture  of  the  femur  went  on  very  well,  ex- 
cepting that  its  obliquity,  with  the  impossibility  of 
producing  a  permanent  extension  on  account  of  the 
leg,  occasioned  a  degree  of  curvature  which  it 
otherwise  would  not  have  had.  The  limb  gra- 
dually acquired  strength,  and  the  patient  is  able 
to  walk  very  well  with  only  the  aid  of  a  small 
stick,  and  even  this  assistance  he  will  probably  not 
require  long.  There  is  no  anchylosis  to  render 
the  ankle  immoveable  ;  but  a  sufficient  firmness 
has  been  produced  in  the  surrounding  parts  by 
the  long  continued  inflammation  to  assist  in  the 
formation  of  an  artificial  joint,  which  possesses  a 
degree  of  motion  nearly  equal  to  that  of  the 
natural. 


304  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS. 

For  the  following  most  interesting  case  1  am  in- 
debted to  Mr  Hicks,  of  Baldock. 

Baldock,  Jngust  \Oth,  1819. 

My  dear  Sir  :  —  In  the  absence  of  my  son,  I  beg 
leave  to  forward  you  the  following  account  of  a  case 
of  compound  dislocation  of  the  ankle. 

Case. — Case  of  John  Curgan.  Early  in  the  morn- 
ing of  November  10,  1812,  the  Stamford  coach, 
from  the  carelessness  of  the  guard  in  neglecting  to 
chain  the  wheel,  ran  with  great  velocity  down  the 
hill  a  mile  below  Baldock,  and  fell  on  its  side  a  little 
before  it  reached  the  foot  of  the  hill ;  in  its  fall,  the 
side  of  the  coach  caught  the  coachman's  right  leg, 
and  turned  the  foot  upon  the  outside  of  the  leg,  by 
which  the  tibia  became  dislocated  on  the  inner  side; 
the  tibia  and  fibula  protruded  through  the  integu- 
ments about  four  inches;  the  oblong  end  of  the 
fibula  was  fractured,  and  several  small  portions  of  it 
remained  within  the  integuments;  the  end  of  the 
tibia  had  some  small  portions  chipped  off,  appearing 
as  if  it  had  been  ground  by  the  side  of  the  coach  ; 
in  this  state  he  was  brought  to  Baldock,  with  his 
foot  dangling  to  his  leg:  the  wound  was  very  large; 
so  much  so,  that  the  foot  appeared  almost  separated 
from  the  leg:  the  ends  of  the  bone  were  covered 
with  dirt. 

Removal  of  the  fragments  of  the  fibula,  —  As  there 
was  not  the  least  chance  of  success  in  returning  the 
tibia  and  fibula  within  the  integuments,  in  this  state, 
and  as  the  patient  was  anxious  for  the  preservation 
of  his  leg,  which  I  likewise  was  very  desirous  to  save, 
I  judged  it  prudent  to  saw  off  the  ends  of  the  tibia 
and  fibula,  the  foot  at  the  same  time  lying  on  a  pil- 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


305 


low  below  the  leg;  after  removing  the  ends  of  the 
tibia  and  fibula,  I  searched  for  the  fractured  portions 
of  the  fibula  left  within  the  integuaients,  by  intro- 
ducing the  fore  finger  of  my  right  hand  into  the 
wound,  and  found  its  external  malleolus  fractured 
into  several  small  pieces,  but  still  adhering  by  its 
ligaments  to  the  astragalus.  Being  fearful  that  these 
shivered  portions  might  be  deprived  of  the  proper- 
ties of  life,  and  that,  if  so,  they  might  produce  much 
mischief,  I  resolved  to  dissect  them  out  by  means  of 
a  bistoury  through  the  wound.  Having  thus  remov- 
ed every  fragment  of  the  fibula,  and  rendered  the 
ends  of  the  tibia  -and  fibula  perfectly  smooth  by 
means  of  a  saw,  not  only  removing  their  fractured 
ends,  but  making  the  separation  as  high  up  as  they 
were  stripped  of  their  periosteum,  about  one  inch 
and  a  half  in  length,  measuring  from  the  malleolus 
internus;  I  then  returned  the  remaining  part  of  the 
tibia  and  fibula  that  had  perforated  the  integuments, 
placing  it  in  a  straight  line  with  the  leg;  the  lace- 
rated integuments  I  brought  into  contact,  and  secur- 
ed them  by  straps  of  adhesive  plaster;  the  limb 
was  then  placed  upon  a  soft  pillow,  supported  by 
Mr  Pott's  long  splints  placed  on  the  outside  of  the 
pillow,  and  fastened  with  tapes;  compresses  of  soft 
linen  cloth  were  applied;  the  leg  was  kept  con- 
stantly wet  with  the  diluted  solution  of  the  acetate 
of  lead,  and  the  following  draught  was  given  for  the 
first  few  days,  every  four  hours,  and  afterwards 
every  six  or  eight,  with  a  regimen  strictly  antiphlo- 
gistic. 

R.  Pulv.  Ipecacuanhae.  c.  gr.  vj. 
Magnes.  Sulphat.  3j. 
Aquae  Purae.  3  ix. 

 Menthae.  3  iij. 

Spt.  Athens  Nitros.  3ss.  M.  Ft.  Haust. 

Through  the  whole  of  the  cure  the  man  went  on 
39 


306  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


remarkably  well,  and  had  little  symptomatic  fever; 
pulse  constantly  below  the  natural  standard,  between 
60  and  70  ;  skin  soft  and  moist ;  the  action  of  the 
intestines  was  regularly  kept  up  by  the  draughts; 
the  integuments  united  by  the  first  intention,  without 
the  least  secretion  of  pus.  On  the  day  seven  weeks 
from  the  accident,  the  patient  was  removed  from 
Baldock  to  his  residence  at  Hewlington,  and  did  not 
require  chirurgical  aid  afterwards.  In  a  few  months 
afterwards  he  paid  me  a  visit  at  Baldock,  walked 
perfectly  well,  and  the  leg  was  very  little  shorter 
than  the  other.  The  last  time  1  saw  him  was  by 
chance  in  April,  181. at  the  Bell  New  Inn, about  three 
miles  below  Baldock,  where  his  coach  stopped,  and 
he  descended  and  ascended  the  box  with  great 
agility. 

I  am,  my  dear  Sir, 

Your's  most  respectfully, 

George  Hicks. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  OUTWARDS. 

My  friend  and  late  dresser,  Mr  Cooper,  of  Brent- 
ford, sent  me  the  following  valuable  communication. 

Case;  longitudinal  fradnre  of  the  tibia, — Tho- 
mas Smith,  aged  thirty-six,  by  trade  a  painter,  whilst 
at  work  on  the  28th  of  October,  1818,  fell  with  a 
ladder  to  the  ground,  when,  his  leg  getting  between 
two  of  its  steps,  the  foot  was  dislocated  inwards. 
The  fibula  was  broken  five  inches  above  the  joint, 
the  tibia  was  fractured  from  the  ankle-joint  longitu- 
dinally about  three  inches  ;  this  small  piece  of  tibia, 
three  inches  in  length,  remained  attached  to  the 
joint  at  the  inner  malleolus,  while  an  inch  and  a  half 


DSLOCATIONS   OF  THE  ANKLE-JOINT. 


307 


of  the  remaining  portion  of  the  tibia,  with  the  ex- 
tremity of  the  fibula,  were  thrust  through  an  opening 
in  the  integuments,  at,  and  rather  anterior  to,  the 
outer  malleolus.  I  was  passing  at  the  time,  and  at- 
tempted by  very  moderate  extension  to  reduce  the 
dislocation ;  this  not  succeeding,  and  finding  the  in- 
teguments tucked  under  the  protruding  portion  of 
bone,  with  a  scalpel  I  dilated  the  wound  anteriorly 
and  posteriorly  about  half  an  inch,  and  then,  by 
means  of  a  metacarpal  saw,  removed  rather  more 
than  an  inch  of  the  tibia,  and  a  small  portion  of  the 
fibula.  This  dislocation  was  now  reduced  without  any 
difficulty.  The  wound  was  closed  by  two  ligatures 
and  a  few  straps  of  adhesive  plaster.  The  patient 
was  placed  on  a  mattress  with  the  limb  on  the  heel, 
enveloped  in  an  eighteen-tailed  bandage,  which  was 
applied  just  sufficiently  tight'  to  give  moderate  sup- 
port, without  producing  or  increasing  tension ;  on 
either  side  was  placed  a  splint,  and  the  limb  was 
kept  constantly  cool  by  means  of  an  evaporating  lo- 
tion. 

Subsequent  to  the  operation,  and  during  the 
whole  of  the  night,  there  was  some  haemorrhagy 
from  the  articular  arteries,  but  not  sufficient  to  in- 
duce me  to  undo  the  limb  in  order  to  secure  the 
bleeding  vessels,  and  I  did  not  open  it  till  the  31st 
of  October,  the  fourth  day,  when  considerable  ad- 
hesion had  taken  place,  and  the  parts  looked  better 
than  I  could  have  expected  ;  but  on  the  eighth  day 
there  was  a  line  of  separation  formed  about  five 
or  six  inches  in  circumference  ;  the  wound  was  now 
fomented,  a  linseed  meal  poultice  was  applied  to  it 
every  six  hours,  and  the  evaporating  lotion  was  still 
applied  to  the  limb  as  far  upwards  as  the  knee. 
On  the  thirteenth  or  fourteenth  day  the  slough 
came  away,  and  healthy  granulations  were  observ- 
able, both  upon  the  integuments,  and  also  upon 


308 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


the  extremity  of  the  tibia;  when  these  granula- 
tions became  exuberant,  they  were  kept  down  by 
the  nitrate  of  silver,  and  the  wound  was  slightly 
dressed  either  with  ungt.  cetacei,  or  equal  parts  of 
ungt.  rcsinae  and  cerat.  calaminae.  In  five  weeks, 
the  wound  was  perfectly  healed ;  the  union  of  the 
fractured  portions  of  the  tibia  went  on  so  well,  and 
the  ossific  deposit  at  the  joint  became  so  firm,  that 
on  Christmas  day,  being  fifty-eight  days  from  the 
time  of  the  accident,  I  found  the  man  sitting  at 
his  table  dining  with  his  family,  and  in  three  months 
he  was  in  the  street,  on  crutches. 

This  patient  had  repeatedly  suffered  much  from 
colica  pictonum;  his  digestive  organs  were  unhealthy, 
and  he  was  a  man  of  nervous  temperament,  all 
which  particulars  I  had  to  discover  after  the  ac- 
cident. As  early  as  the  third  day  he  was  very 
restless;  on  the  fourth,  his  sensorium  was  much 
affected,  and  he  was  constantly  vomiting ;  by  the 
frequent  administration,  however,  of  the  saline  mix- 
ture in  the  act  of  effervescence,  his  stomach  was 
quieted. 

I  ought  to  have  observed  that,  on  the  night  of 
the  accident,  he  took  an  opiate,  and  on  the  follow- 
ing day  I  purged  him  ;  but  from  the  state  of  his 
pulse,  and  from  the  degree  of  hcemorrhagy,  I  did 
not  find  it  requisite  to  take  blood  from  the  arm. 
On  the  eighth  day,  his  stomach  being  tranquil,  we 
were  enabled  to  assist  the  separation  of  the  slough, 
by  invigorating  the  powers  of  the  system  with  bark 
and  port  wine ;  from  half  a  pint  to  a  pint  of  which, 
with  eight  ounces  of  the  decoction  cinchonse  and  opi- 
um, the  quantity  being  regulated  by  his  state  of  irri- 
tability, enabled  him  to  support  the  immense  sup- 
puration at  the  joint,  which,  from  this  time  to  the 
fourth  week,  discharged  most  copiously. 

I  may  here  mention,  that  I  never  observed,  on 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


309 


the  one  hand,  the  stimulating  effects  of  opium,  and 
on  the  other,  its  sedative  effects,  so  strikingly 
exemplified  as  in  this  man  ;  for  if  he  did  not  take 
quite  enough  to  produce  sleep,  he  was  liter- 
ally mad,  tearing  the  bed-clothes,  swearing,  pray- 
ing, singing,  and  making  the  oddest  grimaces  pos- 
sible ;  but  if  he  had  a  full  dose,  which  by  the 
third  week  had  been  increased  to  two  drachms  of 
laudanum,  he  slept  soundly  and  awoke  refreshed; 
and  I  believe  his  extremely  susceptible  state  to 
have  been  such,  that,  but  for  opium,  which  pro- 
duced a  directly  sedative  effect  upon  his  nervous 
system,  he  would  have  sunk  from  constitutional  ir- 
ritation. At  the  end  of  the  second  week,  his 
stomach  being  in  a  fitter  state  for  digestion,  he 
was  allowed  a  plentiful  supply  of  animal  food  and 
good  beer,  with  which,  and  wine,  bark,  and  opium, 
continued  for  a  week  or  two,  he  perfectly  recov- 
ered, 

I  am  Sir,  your's,  etc., 

George  Cooper. 

I  saw  this  man  on  March  the  1st,  1820,  and  I  said, 
*  Would  you  rather  have  your  present  or  an  artificial 
leg?'  — '  Sir,'  said  he,  '  my  injured  leg  is  nearly  as 
useful  to  me  as  the  other;  I  can  go  up  a  ladder,  and 
follow  my  business  as  a  painter,  nearly  as  well  as 
ever.'  A.  C. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  INWARDS. 

Worcester,  July  30th,  1819. 
Dear  Sir:  —  I  have  had  no  case  of  compound  dis- 
location of  the  ankle-joint  under  my  care  since  I  set- 
tled in  practice  ;   but  my  colleague,  Mr  Sandford, 


310  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


gives  me  the  following  information,  which  I  do  myself 
the  pleasure  of  transcribing. 

Case,  —  A  boy,  fifteen  years  of  age,  was  admit- 
ted into  the  Worcester  Infirmary  with  compound 
dislocation  of  the  ankle  ;  the  protruding  portion  of 
the  tibia  was  sawn  off,  the  anterior  tibial  artery  was 
taken  up,  the  limb  was  placed  on  its  outer  side,  the 
wound  dressed  superficially,  and  the  dressings  retain- 
ed with  a  many-tailed  bandage,  kept  wet  with  the 
liq.  ammon.  acet.  Suppuration  and  granulation 
came  on  kindly.  The  boy  wore  tin  splints  for  a 
length  of  time,  and  on  his  recovery  had  a  slight 
motion  of  the  ankle-joint. 

I  am,  my  dear  Sir, 

Your's  very  respectfully, 
J.  Garden. 


COMPOUND  DISLOCATION  OF  THE  TIBIA  OUTWARDS. 

Gloucester^  Sept,  1819. 

Case,  —  My  dear  Sir :  —  Some  domestic  events 
have  delayed  my  reply  to  your  letter.  I  remember 
six  cases  of  compound  dislocation  of  the  ankle-joint, 
four  of  which  underwent  immediate  amputation.  In 
the  two  other  cases  attempts  were  made  to  save  the 
limbs,  and  in  one  with  success.  Most  of  these  acci- 
dents were  produced  by  machinery  ;  and  the  injury 
to  the  joints  and  soft  parts  was  so  great  as  to  destroy 
all  hopes  of  saving  the  limb. 

In  the  limb  that  was  not  saved,  though  the  at- 
tempt was  made,  there  had  been  too  much  mischief 
done,  and,  after  a  trial  of  seven  months,  amputation 
was  performed. 

1  was  called  to  a  fine  young  woman,  eighteen 
years  of  age,  who  had  been  consulting  me  not  an 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  311 


hour  before  on  the  case  of  her  father,  and  who 
having  fallen  from  her  horse,  had  suffered  a  com- 
pound luxation  of  the  ankle-joint  externally.  The 
tibia  and  broken  fibula  protruded  about  an  inch  and 
a  half  through  the  wound  on  the  outside  of  the  limb. 
I  sent  her  to  the  hospital,  and  in  consultation  propos- 
ed that  a  sufficient  quantity  of  the  bones  should  be 
removed  to  admit  of  restoration  ;  I  advised  this  at- 
tempt to  save  the  limb,  from  observing  that  the  ac- 
cident took  place  by  a  heavy  fall  with  the  sole  of  the 
foot  to  the  ground,  that  it  was  unaccompanied  by 
contusions  or  violence  committed  by  a  blow  or 
wrench,  and  that  the  patient  was  a  very  healthy 
country  girl.  There  had  been  considerable  haemorr- 
hage. 

The  extremities  of  the  bones  were  removed,  the 
reduction  accomplished,  and  the  limb  supported  by 
a  tailed  bandage;  splints  were  applied  moderately 
tight,  and  the  bandages  were  directed  to  be  kept 
constantly  soaked  in  a  cold  application.  An  opiate 
was  given. 

On  the  following  day  there  had  been  considerable 
haemorrhage,  but  the  limb  was  not  disturbed.  Great 
suppuration  took  place  about  the  joint,  spread  up 
the  limb,  and  greatly  exhausted  the  patient,  but  she 
recovered.  These  collections  were  never  opened: 
I  should  have  opened  them  early,  and  thus  perhaps 
have  prevented  that  extent  of  suppuration  which  so 
much  reduced  the  patient. 

I  am,  very  faithfully  your's, 

R.  Fletcher. 


The  following  I  received  from  my  friend,  Dr  Lynn. 

Case,  —  A  man  on  board  the  Walmer  Castle, 
East  Indiaman,  in  the  year  1808,  whilst  the  ship  was 


312  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


off  the  Cape  of  Good  Hope,  fell  between  decks,  and 
a  cask  of  water  rolllnoj  upon  his  ankle,  produced  a 
conjpound  dislocation  of  the  end  of  the  tibia  inwards. 
I  sawed  off  the  projecting  portion  of  the  tibia, 
brought  the  parts  as  closely  as  possible  together, 
applied  evaporating  lotions  to  the  linoib,  and  the  man 
recovered  without  any  dangerous  symptoms. 

James  Lynn,  M.D. 


ADDITIONAL  CASES   OF  COMPOUND   DISLOCATION  OF 
THE  ANKLE-JOINT. 

Leicester^  June  29th,  1823. 

Dear  Sir  :  —  Inclosed  I  send  you  the  particulars 
of  the  case  of  compound  dislocation  of  the  ankle-joint, 
as  extracted  from  the  hospital  books  by  Mr  Wilkin- 
son, the  house  surgeon,  to  whom  the  dressing  of  the 
injury  belonged. 

Two  other  cases  have  occurred  to  me  in  private 
practice,  which,  although  I  have  taken  no  particular 
notes,  are  valuable  in  fact,  as  showing  the  efficiency 
of  the  practice  adopted  in  the  detailed  case  which  I 
have  sent  you.  The  wounds  in  the  two  cases  did 
not  heal  by  the  first  intention,  and  the  synovial  fluid 
was  discharged  for  some  time,  yet  they  ultimately 
healed,  and  did  well.  One  of  the  cases,  as  I  have 
since  had  opportunities  of  knowing,  has  completely 
recovered  tlie  free  use  of  the  ankle. 

Case,  —  Catherine  Paddimore,  aged  seventy-two, 
was  admitted  into  the  hospital  on  the  afternoon  of 
September  4,  1821,  from  the  country,  with  compound 
dislocation  of  the  ankle-joint.  She  was  in  the  act  of 
picking  up  pears,  when  her  husband  fell  from  the 
tree,  and  lighted  on  her  back,  which  occasioned  the 
accident.    On  examination,  after  removing  a  consid- 


DISLOCATIONS  OF   THE  ANKLE-JOINT.  313 


erable  quantity  of  blood,  the  inferior  extremity  of 
the  tibia  of  the  right  leg  was  protruding  nearly  three 
inches  through  a  laceration  of  the  integuments;  the 
foot  turned  completely  outward ;  •  the  fibula  was 
fractured  in  two  places.  The  patient  being  placed 
in  bed  on  her  right  side,  and  the  wound  being  clean- 
ed, the  knee  was  flexed,  and,  with  moderate  exten- 
sion, the  dislocated  tibia  was  reduced,  and  the  fibula 
adjusted.  The  wound  was  approximated  with  ad- 
hesive straps ;  M.  Dupuytren's  splint  and  bandage, 
and  an  evaporating  lotion  were  applied.  The  patient 
was  retained  on  the  right  side,  and  the  limb  flexed: 
she  was  verv  much  exhausted.  Her  bowels  were 
soon  acted  on  by  the  sulphate  of  magnesia. 

September  5th.  No  sleep;  tongue  furred ;  pulse 
frequent  and  strong;  bowels  well  opened;  no  great 
pain  of  the  ankle,  and  trifling  swelling.  Fiat  vene- 
sectio  e  brachio  ad  3  xx.  vespere.  Pain  and  swell- 
ing of  the  ankle  a  little  increased;  pulse  frequent 
and  soft.  Admoveantur  hirudines  No.  xvi.  statim. 
She  takes  liq  :  ant:  tart, small  doses  of  the  sulphate 
of  magnesia,  with  a  febrile  julep,  every  three  hours. 

September  6th.  Slept  several  hours  ;  pulse  fre- 
quent and  soft ;  skin  comfortable  ;  bowels  not  open 
since  yesterday  ;  tongue  furred  ;  makes  no  complaint 
of  the  leg,  which  looks  remarkably  well.  She  re- 
peated the  sulphate  of  magnesia. 

September  8th.  No  pain  or  swelling  about  the 
ankle-joint ;  bowels  open. 

September  9th.  The  wound  was  dressed  ;  the 
adhesive  process  far  exceeded  expectation  ;  no  pain. 

September  13th.    Wound  healing. 

September  28th.    Wound  well. 

October  4tb.    Allowed  to  sit  up. 

October  13th.    Can  walk  with  crutches, 
40 


314        DISLOCATIONS   OF  THE  ANKLE-JOINT. 


She  has  now  perfect  use  of  the  joint,  and  could 
walk  very  well  last  summer,  without  crutches. 

Your's  very  truly, 

John  Needham. 


DISLOCATION   OF  THE  ANKLE  OUTWARDS. 

Case,  —  William  Thomas,  aged  eighteen,  was  ad- 
mitted into  Guy's  Hospital,  June  28th,  1823,  with 
a  compound  dislocation  of  the  ankle  outwards,  caus- 
ed by  a  hogshead  of  tobacco  falling  upon  his  leg. 

The  foot  was  doubled  inwards,  and  the  malleolus 
externus  broken,  which  being  immediately  removed, 
the  limb  was  placed  upon  a  splint  on  its  inner  side, 
with  the  knee  bent,  two  sutures  were  applied  to 
bring  the  edges  of  the  wound  together,  and  a  piece 
of  lint  placed  over  it ;  the  leg  was  kept  well  wetted 
with  the  liq  :  plumb:  acet:  dil.  The  patient  was 
ordered  to  take  forty  drops  tinct :  opii:,  and  not  to 
be  disturbed. 

June  29th.  Ordered  calomel  gr.  v,  and  an  ape- 
rient draught  to  be  taken  afterwards. 

June  30th.  The  lint  was  removed  from  the 
wound,  and  a  poultice  ordered  :  no  febrile  symp- 
toms appearing,  this  treatment  was  continued,  with- 
out medicine,  till  July  14th. 

July  15th.  The  opiate  lotion  was  ordered  instead 
of  the  poultice. 

July  16th,  17th.    The  same  treatment  continued. 

July  18th.  He  passed  a  restless  night,  and  had  a 
white  tongue  and  quick  pulse  ;  with  inflammation 
and  swelling  of  the  leg;  complained  of  great  p^in. 
Ordered  the  saline  draught  every  three  hours. 

July  25th.  Matter  formed  along  the  tibia ;  an 
opening  was  made,  and  a  large  quantity  evacuated  ; 


DISLOCATIONS   OP  THE  ANKLE-JOINT. 


315 


a  poultice  was  applied  over  the  opening,  and  the 
opiate  lotion  continued  to  the  wound. 

July  28th.  It  was  now  judged  expedient  to 
change  his  diet,  and  his  medicines  :  he  was  allowed 
animal  food  with  porter;  and  bark,  with  ammonia, 
was  given  every  six  hours. 

August  6th.  Matter  had  again  formed;  another 
opening  was  made, and  the  same  treatment  pursued; 
his  diet  and  m.edicines  were  continued  as  before. 
After  this  period  he  rapidly  recovered,  and  at  the 
latter  end  of  the  month  was  able  to  rise  from  his 
bed.    The  wound  always  looked  healthy. 


DISLOCATION  OF  THE   ANKLE  FORWARDS. 

JVew  Bridge  Street^  Blackfriars ; 

Marck  4th,  IH24. 

My  dear  Sir:  —  I  have  much  pleasure  in  sending 
you  an  account  of  the  case  I  mentioned  to  you  last 
night,  together  with  a  sketch  by  which  I  have  en- 
deavoured to  show  the  position  of  the  limb  at  the 
time  when  I  saw  the  patient. 

Case,  —  James  Price,  aged  thirty-nine,  a  very  ro- 
bust man,  was  coming  to  town  on  iMonday,  the  ist  of 
March,  in  a  light  cart,  drawn  by  one  horse.  In 
passing  through  Clapham  the  horse  ran  away,  and 
falling,  overturned  the  cart,  and  threw  Price's  legs 
under  one  of  the  shafts  ;  in  endeavouring  to  extri- 
cate himself,  he  received  a  severe  injury  to  the  right 
ankle.  By  the  direction  of  Mr  Parratt,  he  was  im 
mediately  conveyed  to  St  Thomas's  Hospital,  where 
I  saw  him  ;  and,  on  examination,  found  that  the  tibia 
had  been  dislocated  forwards,  and  a  little  inwards, 
its  inferior  extremity  resting  on  the  fore  part  of  the 
astragalus  and  os  naviculare:  the  deltoid  ligament 
must  have  been  torn  through,  as  the  inner  malleolus 
was  not  fractured.    The  heel  projected  very  consid- 


316  DISLOCATIONS  OF  THE  ANKLE-JOINT. 


erably,  and  the  foot  was  turned  outwards  in  a  slight 
degree  and  downwards,  the  toes  being  pointed.  The 
fibula  was  fractured  about  two  inches  above  the 
external  malleolus,  at  which  part  there  was  a  con- 
siderable depression.  The  reduction  was  very  ea- 
sily accomplished  by  flexing  the  leg  on  the  thigh, 
Avhich  was  firmly  held  by  my  dresser,  Mr  Campbell, 
as  I  drew  the  foot  downwards  and  forwards,  and 
pressed  the  tibia  backwards.  The  limb  was  placed 
in  the  flexed  position,  on  the  heel;  since  which  time 
the  patient  has  been  perfectly  tranquil,  and  the  limb 
remains  in  its  proper  position. 

Believe  me,  your's  most  sincerely, 

Frederick  Tyrrell. 

Experiment, 

I  was  anxious  to  ascertain  what  steps  nature  pur- 
sued in  order  to  restore  a  oart  in  which  the  ex- 
tremity  of  a  bone,  forming  a  joint,  had  been  sawed 
off ;  and  I  therefore  instituted  the  following  experi- 
ment. 

I  made  an  incision  upon  the  lower  extremity  of 
the  tibia,  at  the  inner  ankle  of  a  dog,  and  cutting 
the  inner  portion  of  the  ligament  of  the  ankle-joint, 
I  produced  a  compound  dislocation  of  the  bone  in- 
wards. I  then  sawed  off*  the  whole  cartilaginous 
extremity  of  the  tibia,  returned  the  bone  upon  the 
astragalus,  closed  the  integuments  by  suture,  and 
bandaged  the  limb  to  preserve  the  bone  in  this  situ- 
ation. Considerable  inflammation  and  suppuration 
followed  ;  and  in  a  week  the  bandage  was  removed. 
When  the  wound  had  been  for  several  weeks  per- 
fectly healed,  I  dissected  the  limb.  The  ligament 
of  the  joint  was  still  defective  at  the  part  at  which 
it  had  been  cut.  From  the  sawn  surface  of  the 
tibia  there  grew  a  llgamento-cartilaginous  substance, 
which  proceeded  to  the  surface  of  the  cartilage  of 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  317 


the  astragalus,  to  which  it  adhered.  The  cartilage 
of  the  astragalus  appeared  to  be  absorbed  only  in 
one  small  part ;  there  was  no  cavity  between  the 
end  of  the  tibia  and  the  cartilaginous  surface  of  the 
astragalus.  A  free  motion  existed  between  the  tibia 
and  astragalus,  which  was  permitted  by  the  length 
and  flexibility  of  the  ligamentous  substance  above 
described,  so  as  to  give  the  advantage  of  a  joint 
where  no  synovial  articulation  or  cavity  was  to  be 
found.  This  experiment  not  only  shows  the  man- 
ner in  which  the  parts  are  restored,  but  also  the 
advantage  of  passive  motion :  for  if  the  part  be  fre- 
quently moved,  the  intervening  substance  becomes 
entirely  ligamentous  ;  but  if  it  be  left  perfectly  at 
rest  for  a  length  of  time,  ossific  action  proceeds 
from  the  extremity  of  the  tibia  into  the  ligamentous 
substance,  and  thus  produces  an  ossific  anchylosis. 


CASES  WHICH  RENDER  AMPUTATION  NECESSARY. 

Cases  requiring  amputation,  8rc, — But  still  cases 
occur  in  which  amputation  is  found  absolutely  neces- 
sary, either  to  preserve  the  life  of  the  patient,  or  to 
prevent  his  being  doomed  to  the  constant  necessity 
of  using  crutches  on  account  of  the  deformity  and 
stiffness  of  the  limb. 

It  seems  to  me,  however,  to  be  by  much  too  pre- 
vailing an  opinion,  that  the  amputation  of  the  limb 
is  a  sure  means  of.  preserving  life  ;  for  when  this 
operation  used  to  be  more  frequently  performed  in 
our  hospitals  than  it  now  is,  for  compound  disloca- 
tion of  the  ankle  and  compound  fracture  of  the  leg, 
a  considerable  number  of  our  patients  died.  Very 
lately  a  man  at  Tring  had  his  foot  torn  off  by  a 
threshing  machine,  and  the  limb  was  obliged  to  be 
amputated  at  the  usual  place  below  the  knee.  The 


318         DISLOCATIONS  OF  THE  ANKLE-JOINT. 


operation  was  performed  by  Mr  Firth,  but  the  man 
died  in  the  evening  of  the  sixth  day;  and  a  case  has 
occurred  since  the  pubHcation  of  the  second  edition 
of  my  Essays  of  equally  fatal  termination. 

The  circumstances  which  1  have  known  to  create 
this  necessity  are, 

(1.)  The  advanced  age  of  the  Patient, 
Age, — Under  great  age  the  powers  of  the  body 
become  so  much  w^eakened,  that  the  patient  is  unable 
to  bear  the  constitutional  excitement  which  the  sup- 
purative inflammation  of  the  joint  produces  ;  and  as 
amputation  does  not  expose  him  to  this  process,  it  is 
better  to  have  recourse  to  that  operation.  How- 
ever, I  ought  to  observe,  that  w^hen  in  my  lectures 
I  have  stated  what  I  have  now  advanced,  the  pupils 
have  flocked  around  me  after  lecture,  and  have  told 
me  of  cases  of  recovery,  even  of  very  old  persons; 
bu-t  in  the  practice  of  hospitals  in  this  great  metro- 
polis, very  aged  persons  sink  under  these  accidents, 
if  the  limb  be  not  amputated. 

(2. )  A  very  extensive  lacerated  Wound  will  give  rise  to 
a  necessity Jor  this  operation. 

Case;  laceration,  —  July  10th,  1806,  Mr  Dudin^ 
a  gentleman  residing  in  Horsley-down,  Borough, 
jumped  out  of  his  one-horse  chaise,  and  dislocated 
the  tibia  inwards  at  the  ankle,  through  a  large  lace- 
rated wound,  and  a  portion  of  the  malleolus  internus 
was  broken  ofl"  and  remained  attached  to  the  astra- 
galus. The  wound  bled  freely,  and  the  foot  was 
loose  and  pendulous;  I  therefore  felt  myself  obliged 
to  amputate  the  limb. 

Mr  D.,  after  this  operation,  proceeded  in  every 
respect  favourably;  recovering  without  any  unto- 
w^ard  symptom. 

Case,  —  James  Morrise,  aged  thirty-six,  was  ad-  • 


niSLOCATIONS   OF  THE  ANKLE-JOINT.  3l9 

mitted  into  St  Thomas's  Hospital,  on  the  29th  of 
January,  1824,  under  the  care  of  Mr  Green,  with  a 
dislocation  of  the  ankle-joint,  in  consequence  of 
having  his  leg  caught  in  the  coil  of  a  rope,  to  which 
a  great  weight  was  appended. 

The  injury  was  accompanied  with  so  much  loss 
of  integument  that  immediate  amputation  was  pro- 
posed, to  which  the  man  would  not  give  his  consent. 
Mr  Green  sawed  off  the  end  of  the  bone  and  replaced 
the  tibia  upon  the  astragalus  ;  but  the  end  of  the  tibia, 
from  deficiency  of  skin,  still  remained  exposed. 
The  constitutional  and  local  irritation  which  followed 
rendered  it  necessary  to  amputate  the  limb,  which 
was  done  on  March  the  19th,  being  seven  weeks 
and  one  day  after  the  accident.  With  Mr  Green's 
permission  I  then  dissected  it,  and  the  followinfij  is  the 


Dissection. 

The  cellular  membrane  was  loaded  with  serum; 
all  the  muscles  remained  in  a  sound  state,  but  the 
tendon  of  the  tibialis  anticus  was  partially  torn,  as 
was  that  of  the  peroneus  tertius  ;  'those  of  the  tibia- 
lis posticus,  and  flexor  longus  digitorum  pedis,  adher- 
ed strongly  to  the  posterior  portion  of  the  capsular 
ligament.  An  abscess  extended  between  the  tibia- 
lis posticus  and  gastrocnemius  muscles  from  the  ankle 
nearly  to  the  place  of  amputation.  The  arteries 
anvl  nerves  were  undivided,  but  the  anterior  tibial 
artery  was  greatly  diminished  by  the  altered  posi- 
tion and  pressure  of  the  tibia.  The  deltoid  liga- 
ment, the  anterior  part  of  the  capsular,  and  the  liga- 
ment of  the  tendon  of  the  tibialis  anticus,  were 
torn  through.  The  fibula  was  broken  four  inches 
from  the  ankle-joint ;  its  lower  fractured  extremity 
overlapped  the  upper  about  an  inch,  and  the  latter 
was  situated  between  the  lower  portion  of  the  fibula 


320 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


and  the  tibia.  The  bones  were  not  completely  unit- 
ed, and  the  fibula  was  exfoliating  at  the  upper  end 
of  the  lower  portion;  a  part  of  the  fibula  also  re- 
mained detached,  which  had  been  broken  off  at  the 
time  of  the  accident.  The  lower  end  of  the  tibia 
was  dead  and  exfoliating,  and  rested  but  partially 
upon  the  astragalus  :  its  periosteum  was  much  thick- 
ened above  the  exfoliating  part.  The  outer  poste- 
rior portion  of  the  tibia  next  the  fibula  was  broken 
off,  and  strongly  adhered  to  the  fibula.  The  surface 
of  the  astragalus  was  in  parts  deprived  of  its  car- 
tilage by  ulceration. 

The  exposure  and  consequent  exfoliation  of  the 
tibia,  the  exfoliation  of  the  fibula,  and  the  large 
abscess,  led  to  the  necessity  for  amputation. 

(3.)  A  difficulty  in  reducing  the  Bones  has  been  con- 
sidered as  a  reason jor  amputation. 
Difficult  reduction.  — This  circumstance,  however, 
is  rather  a  motive  for  removing  the  extremities  of 
the  bones  by  the  saw  than  for  performing  amputa- 
tion ;  after  which  removal  the  reduction  of  the 
tibia  is  easily  effected,  and  a  useful  limb  is  preserv- 
ed to  the  patient. 

(4.)  The  Bones  are  sometimes  extremely  shattered. 
Bones  shattered,  —  If  the  lower  extremity  of  the 
tibia  be  broken  into  small  pieces,  the  loose  portions 
of  bone  ought  to  be  removed,  and  the  end  of  the 
tibia  to  be  smoothed  by  a  saw  ;  but  if,  in  addition 
.  to  this  comminution,  the  lower  extremity  of  the 
tibia  be  obliquely  broken,  and  a  large  loose  portion 
of  bone  be  felt  with  the  fingers,  then  it  will  be 
roper  to  amputate  :  also,  if  the  astragalus  be  bro- 
en,  the  portions  of  this  bone  should  be  removed, 
otherwise  they  will  separate  by  ulceration,  or  occa- 
sion considerable  local  irritation.    (See  Dr  Lynn's 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


321 


and  Dr  Rurasey's  cases )  But  if  the  end  of  the 
tibia  and  the  tarsal  bones,  as  the  astragalus  and  os 
tialciS,  are  broken,  then  amputation  will  be  requir- 
ed. The  following  case  clearly  shows  the  necessity 
of  the  operation  in  such  a  state  of  parts. 

Case,  —  I  was  requested  to  see  a  lady,  aged  thirty- 
four  years,  who,  on  August  the  Oth,  1819,  had,  in  a 
fit  of  insanity,  jumped  out  of  a  two  pair  of  stairs 
window,  and  produced  a  compound  dislocation  of  the 
tibia  and  fibula  at  the  outer  ankle.  At  the  lady's 
residence  I  met  Mr  Stephens,  a  surgeon  residing  in 
Hunter- street,  Brunswick-square,  who  had  been 
called  immediately  after  the  accident.  As  she  ap- 
peared almost  insensible,  and  Mr  Stephens  feared 
an  injury  to  the  brain,  he  took  away  twelve  ounces 
of  blood.  When  he  examined  the  ankle,  he  found 
the  malleolus  externus  of  the  fibula  projecting 
through  the  wound,  but  unbroken,  the  tibia  dislo- 
cated and  broken,  and  the  foot  verj  much  turned 
inwards.  He  extended  the  foot,  and  thought  that 
the  bones  had  exactly  returned  into  their  natural 
situation;  adhesive  plaster  was  applied  upon  the 
wound,  and  its  edges  were  nicely  adjusted.  She 
was  placed  on  a  mattress  with  the  limb  upon  the 
heel,  and  with  a  splint  on  each  side  of  the  leg. 
For  seven  days  she  complained  of  tittle  pain,  and 
had  but  slight  constitutional  disturbance.  On  the 
day  week  from  the  accident  I  was  requested  to 
see  her;  and  finding  little  local  or  constitutional 
irritation,  I  recommended  that  the  limb  should  not 
be  disturbed,  and  the  dressings  were  not  removed, 

On  the  tenth  day  from  the  accident,  Mr  Stephens 
finding  her  in  more  pain  examined  the  wound,  and 
found  that  it  had  not  adhered. 

On  the  twelfth  day,  a  considerable  discharge  issu- 
ed from  the  wound. 

On  the  sixteenth  day  a  slough  had  separated  and 


322  DISLOCATIONS  OF  THE  ANKLE-.IOlNt. 


exposed  the  bones,  which  appeared  shattered  and 
projecting.  On  this  day  I  again  saw  her,  and  upon 
examining  the  ankle  found  the  astragalus  projecting, 
and  a  portion  of  it  broken;  and  as  the  surrounding 
parts  were  dead  I  removed  the  projecting  bone. 
Introducing  my  finger  into  the  wound  as  soon  as  the 
astragalus  had  been  separated,  the  tibia  was  found 
to  be  shattered,  and  the  os  calcis  broken  into  many 
pieces.  As  her  pulse  was  100  and  small,  and  her 
strength  was  failing,  I  Immediately  recommended 
her  to  submit  to  the  operation  of  amputation,  to 
which  she  consented. 

On  the  Monday  following,  the  stump  was  dressed 
by  Mr  Stephens,  and  the  greater  part  was  adhering. 

Two  of  the  ligatures  separated  on  the  tenth  day, 
and  the  other  came  away  on  the  sixteenth  day. 

September  29th.  The  stump  was  healed,  ex- 
cepting about  the  size  of  the  section  of  a  pea,  and 
she  had  no  complaint  remaining  excepting  a  sore 
upon  her  back,  and  pain  in  her  left  foot. 

It  is  proper  to  mention  that  she  hurt  her  spine 
and  kidneys  by  the  fall,  so  as  to  discharge  urine 
tinged  with  blood  for  three  weeks  after  the  acci- 
dent. 

The  other  ankle  also  was  most  severely  injured^ 
and  she  suffered  exceedingly  from  pain  in  it. 

Upon  examination  of  the  amputated  limb,  the 
tibia  was  split  up  from  the  malleolus  internus  to 
the  extent  of  three  inches;  the  fibula  was  unbrok- 
en ;  the  astragalus  was  broken  and  detached  ;  and 
the  OS  calcis  was  fractured  into  several  pieces. 

I  have  lately  had  another  case  of  the  same  kind 
in  which  I  was  obliged  to  amputate.    {See  Plate.) 

(5.)  The  Dislocation  of  the  Tibia  at  the  Outer  Ankle ^ 
Produces  much  more  injury  and  danger  than 
that  at  the  inner,  and  amputation  will  be  more  fre- 


DISLOCATIONS  OF   THE  ANKLE-JOINT. 


323 


quently  required  for  it,  because  both  the  bones  and 
soft  parts  suffer  more  than  in  the  dislocation  inwards. 

(6.)    It  sometimes  happens  that  when  the  Bone  is 
replaced^  it  will  not  remain  in  its  Situation,  and  all 
the  Symptoms  of  the  Injury  become  renewed. 
Oblique  fracture  with  dislocation.  —  This  circum- 
stance arises  when  the  tibia,  in  the  dislocation  out- 
wards, is  obliquely  broken;   and  as  only  a  small 
portion  of  the  articulating  surface  remains  on  the 
dislocated  extremity  of  the  tibia,  it  will  not  rest  on 
the  tibia  when  it  is  reduced. 

Mr  Andrews,  of  Stanmore,  and  Mr  Foote,  of 
Edgware,  consulted  me  on  the  following  case. 

Case,  —  Mr  Andrews  and  Mr  Foote  were  sent 
for  on  August  the  9th,  1817,  to  the  Hyde,  six  miles 
from  London,  to  visit  Charles  Tomlin,  a  higgler, 
forty-eight  years  of  age,  who  falling  in  a  state  of 
intoxication,  the  wheel  of  his  cart  passed  over  his  left 
leg,  and  produced  a  protrusion  of  the  bones  through 
the  integuments  at  the  outer  ankle.  Mr  Andrews 
reduced  the  dislocation  in  the  evening  of  the  acci- 
dent. On  the  same  night  Mr  Andrews  and  Mr 
Foote  having  visited  him  again,  found  his  pulse  very 
quick,  and  spasms  in  the  limb,  which  had  again  dis- 
placed the  bone.  They  gave  him  a  large  dose  of 
opium,  and  succeeded  in  reducing  the  bones. 

On  the  10th,  he  had  a  very  quick  pulse,  accom- 
panied with  strong  spasms  in  the  limb,  but  not  suf- 
ficiently severe  to  displace  the  bone. 

On  the  nth,  I  was  requested  by  Mr  Andrews  and 
Mr  Foote,  as  1  was  going  through  the  village,  to  stop 
and  see  this  man  ;  and  as  soon  as  the  bandages  were 
removed  a  violent  spasm  threw  the  bones  from  the 
astragalus,  and  all  the  efforts  I  could  make  would  not 
replace  them.  Seeing,  therefore,  no  hope  of  the  man's 
recovering  without  the  amputation  of  the  limb  1  im- 
mediately proposed  it,  and  he  readily  gave  his  consent. 


324  DISLOCATIONS  OF  THE  ANKLE-JOlNT. 


For  three  or  four  days  he  had  a  great  deal  of 
nervous  irritation,  which  was  most  etfectuallj^  re- 
h'eved  by  occasional  doses  of  opium  and  gether. 

On  the  18th  the  stump  was  inflamed  and  in  some 
parts  sloughy ;  and  on  the  22nd  it  bled  profusely. 

On  the  23th  a  poultice  was  applied;  and  from 
this  time  the  appearance  of  the  stump  improved, 
and  he  proceeded  without  interruption  in  his  recov- 
ery. In  a  month  he  returned  to  his  home  at  Bushey, 
a  distance  of  seven  miles. 

Upon  examination  of  the  limb  I  found  the  cellular 
membrane  around  the  ankle  loaded  with  extravasat- 
ed  blood  ;  the  ligamentum  annulare  tarsi  was  torn. 
The  muscles  were  all  remaining  whole,  though  some 
of  them,  as  the  peronei,  were  much  put  upon  the 
stretch.  The  fibula  was  broken  one  inch  above  the 
lower  extremity  of  the  malleolus  externus,  which 
remained  in  its  place,  still  united  by  its  ligaments  to 
the  tarsus.  .The  tibia  was  split  down  from  two 
inches  above  the  joint,  leaving  the  greater  part  of 
the  articulating  surface  still  resting  upon  the  astra- 
galus; but  the  remaining  portion  of  the  articulating 
surface,  with  the  shaft  of  the  tibia  and  the  fibula, 
passed  through  the  wound  at  the  outer  ankle.  If, 
therefore,  the  bone  had  been  again  returned  to  its 
situation,  it  could  not  have  remained  there,  from  the 
small  portion  of  articulating  surface  attached  to  it ; 
and  if  the  projecting  portion  had  been  removed  by 
the  saw,  it  would  not  have  adapted  itself  to  the 
portion  of  the  tibia  which  remained  attached  to  the 
astragalus. 

(7.)  The  Division  of  a  large  Blood-Vessel  mighty 
with  an  extensive  Wound  of  the  Integuments,  lead  to 
a  necessity  for  j^mputation. 

Division  of  an  artery.  —  But  I  should  not,  on  that 
account,  at  once   proceed  to  the  operation.  The 


DISLOCATIONS  OF  THE  ANKLE-JOINT. 


325 


case  from  Mr  Sandford,  of  Worcester,  sent  me  by  Mr 
Garden,  clearly  shows  that  the  division  of  the  anteri- 
or tibial  artery  does  not,  if  it  be  well  secured,  pre- 
vent the  patient's  recovery.  I  also  once  saw  a  com- 
pound fracture  close  to  the  ankle-joint,  accompanied 
by  a  division  of  that  artery  ;  yet,  although  the  patient 
was  in  the  hospital,  and,  being  a  brewer's  servant, 
possessed  the  worst  constitution  to  struggle  against 
severe  injuries,  this  man  recovered  without  amputa- 
tion. 

The  posterior  tibial  artery  is  a  vessel  of  more  im- 
portance, and  is  accompanied  by  a  large  nerve,  which 
would  not  be  likely  to  escape  injury  when  the  artery 
was  divided  by  the  dislocated  bone.  Yet  the  mag- 
nitude of  the  anterior  tibial  artery,  and  its  free  anas- 
tomosis with  the  posterior,  would  not  entirely  pre- 
clude the  hope  of  preserving  the  foot  under  an  injury 
of  the  posterior  tibial  artery. 

(8.)    Mortification  of  the  Foot 

Sometimes  ensues,  and  becomes  a  sufficient  reason 
for  amputating  the  limb  ;  but  this  must  be  generally 
done  when  limits  appear  to  be  set  to  the  extension 
of  the  mortification.  However,  it  may  be  observed, 
that  in  the  mortification  which  ensues  from  the  di- 
vision of  a  blood-vessel,  where  the  brachial  artery 
had  been  divided,  and  the  elbow-joint  dislocated,  I 
have  seen  the  arm  removed  above  the  injured  part, 
while  the  limb  was  still  dying  towards  the'  seat  of 
the  wounded  artery,  and  the  patient  was  restored  to 
health.  And  I  have  also  known  a  case  of  popliteal 
aneurism,  in  which  the  artery  and  surrounding  parts 
were  so  compressed  by  the  swelling,  that  mortifica- 
tion began  at  the  foot,  and  was  extending  to  the 
knee;  and,  although  no  limit  was  yet  set  to  the 
mortification,  the  limb  was  amputated,  and  the  pa- 


326  DISLOCATIONS   OF  THE  ANKLE-JOINT. 


tient  recovered.  So  that  mortification,  when  it 
arises  from  injury  to  a  blood-vessel,  or  other  local 
injury,  in  a  healthy  constitution,  admits  of  a  practice 
different  from  that  which  is  pursued  in  mortification 
arising  from  constitutional  causes. 

Excessive  contusion  may  he  another  reason  for 
Jlmputalion  ; 
And  therefore  in  those  cases  in  which  hea- 
vy laden  carriages  pass  over  joints,  and  bruise 
the  integuments  so  as  to  occasion  the  formation 
of  extensive  slough,  and  produce  at  the  same 
time,  generally,  the  worst  examples  of  compound 
dislocation,  in  regard  to  the  state  of  the  bones,  I 
should  immediately  amputate  ;  for  such  cases  are 
very  different  from  those  which  are  caused  by  jump- 
ing from  a  considerable  height,  from  a  carriage  ra- 
pidly in  motion,  or  by  a  fall  in  walking  or  running. 

Extensive  Suppuration  will  also  be  a  reason  for 
Amputation. 

Suppuration,  —  I  have  known,  after  an  attempt 
to  save  the  limb,  the  patient  have  more  extensive 
suppuration  than  his  constitution  could  support,  fol- 
lowed by  an  ulceration  of  the  ligaments,  by  which 
the  joint  became  additionally  exposed,  and  the  bones 
were  again  displaced;  hence  there  arose  an  absolute 
necessity  to  remove  the  limb  for  the  preservation  of 
his  life. 

(9.)  A  necessity  for  Amputation  may  also  he  produc- 
ed hy  Exfoliations  of  Portions  of  Bone, 
Which,  locked  in  the  surrounding  parts  of 
the  bone,  are  incapable  of  becoming  separated, 
and  thus  keep  up  a  state  of  continued  irrita- 
tion.   My  friend,  Mr  Hammick,  had  the  kindness 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


32t 


to  send  me  a  specimen  of  this  kind,  which  he  was 
obliged  to  amputate.  The  loose  portion  of  bone 
was  seated  between  the  lower  extremity  of  the 
tibia  and  fibula,  and  reached  to  the  ankle-joint ;  both 
the  bones  had  been  broken  and  had  become  reunit- 
ed, and  the  uniting  medium  had  inclosed  and  incar- 
cerated the  dead  portion  of  bone.  It  is  probable, 
from  the  appearance  of  the  parts,  that  this  portion 
of  bone  never  would  have  been  able  to  escape  from 
the  place  in  which  it  was  locked.    (See  Plate.) 

(10.)  Excessive  Deformity  of  the  Foot 
Will  also  give  rise  to  a  necessity  for  ampu- 
tation; and  this  deformity  will  take  place  in 
three  directions.  First,  when  the  foot  is  suffered 
to  turn  outwards,  whilst  the  leg  is  placed  upon  the 
heel,  in  the  dislocation  inwards.  Secondly,  when  it 
is  turned  inwards  ;  and  thirdly,  when  the  foot  re- 
mains pointed.  The  first  is  best  opposed  by  placing 
the  leg  upon  its  outer  side,  when  that  is  compatible 
with  the  treatment  of  the  wound ;  in  the  second 
case  it  is  best  to  keep  the  foot  on  the  heel;  and  in 
both  cases,  splints,  having  a  foot-piece  both  on  the 
inner  and  outer  side  of  the  foot,  must  be  applied  : 
the  third  requires  similar  splints,  and  a  (ape,  as  a 
stirrup,  placed  under  the  foot,  and  fastened  to  the 
splint  on  the  fore  and  middle  part  of  the  leg  to  keep 
the  foot  supported.  The  splints  should  be  so  pad- 
ded as  to  preserve  it  in  its  proper  direction.  (See 
Plate.) 

The  following  case  from  Mr  Norman,  of  Bath, 
shows  the  necessity  for  amputation,  when  great  de- 
formity is  permitted  to  occur. 

Case.  —  I  was  sent  for  to  Bradford,  some  years 
since,  to  amputate  a  leg  directly  after  an  accident 
of  this  kind.    I  found  the  lower  extremity  of  the 


328  DISLOCATIONS  OF  THE  ANKLE-JOlNTi 


tibia,  with  the  astragalus  loosely ^^attached  to  it,  pro- 
jecting at  the  inner  ankle.  The  wound  was  not 
large,  and  the  soft  parts  were  little  injured.  I  re- 
moved the  astragalus,  and  reduced  the  tibia,  leav- 
ing it  to  rest  upon  the  os  calcis.  I  did  not  again 
^ee  my  patient  during  the  healing  of  the  wound; 
I  believe  it  got  well  without  any  severe  symptoms, 
but  the  OS  calcis  was  drawn  up  against  the  poste- 
rior part  of  the  tibia,  to  which  it  firmly  united,  and 
the  foot  became  immovable,  with  the  toe  pointed 
downwards.  In  this  state  he  came  to  Bath  two 
years  afterwards,  when  I  amputated  the  leg,  and 
the  patient  did  well. 

Bath^  August  2nd,  1819.       George  Norman. 

(11.)  Amputation  has  been  recommended  in  those 
cases  in  which  Tetanus  occurs  after  this  Injury. 
Tetanus ;  case,  —  Of  tetanus  I  have  seen  one 
case  from  compound  dislocation  of  the  ankle,  and 
have  heard  of  another.  That  which  I  saw  was  in 
a  Mr  Yare,  stable-keeper,  who  had  a  compound 
dislocation  of  the  tibia  inwards,  and  in  whom  I  re- 
duced the  bones,  and  placed  the  limb  on  its  outer 
side.  For  a  few  days  he  proceeded  without  any 
alarming  symptoms.  The  only  circumstance  in 
which  his  case  differed  from  what  I  expected  was 
in  the  slight  inflammation  which  succeeded  upon 
the  joint,  for  the  restorative  process  seemed  to  be 
scarcely  established  in  him.  When  I  paid  him  my 
morning  visit,  several  days  after  the  accident,  he 
said,  '  Sir,  I  believe  I  have  caught  cold,  for  my 
neck  is  stiff;'  and  as  he  said  this  with  his  lower  jaw 
raised  and  his  teeth  closed,  I  begged  him  to  show 
me  his  tongue,  to  ascertain  if  the  jaw  was  locked  ; 
and  he  tried  to  open  his  mouth,  but  was  unable  to 
do  so.    I  then  desired  that  Dr  Relph  might  see 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  329 


him,  who  did  all  that  his  mind  could  suggest  to  ar- 
rest the  progress  of  the  symptoms,  but  unsuccess- 
fully, as  the  different  muscles  of  volition  became 
affected  in  the  back,  the  extremities  and  the  abdo- 
men, until  he  was  exhausted  by  irritation.  To  am- 
putate under  such  circumstances  would  be  most  un- 
justifiable, as  far  as  the  experience  of  cases  in  this 
climate  will  enable  me  to  form  an  opinion.  I  have 
not  seen  amputation  performed  for  compound  dislo- 
cation of  the  ankle,  but  I  have  seen  it  performed 
for  compound  fracture  just  above  the  joint,  and  it 
seemed  to  me  to  precipitate  the  fatal  event.  I 
have  also  known,  in  one  case,  the  finger  amputated 
for  tetanus  arising  from  injury  to  it,  yet  the  patient 
died  ;  and  1  have  also  heard  of  a  third  case  in  which 
it  was  practised,  but  still  the  issue  was  fatal.  There 
is  a  species  of  chronic  tetanus,  which  sometimes  even 
succeeds  wounds,  and  which  will  occasionally  subside, 
and,  apparently,  the  patient  will  recover,  although 
little  be  done  by  medicine,  and  nothing  by  surgery; 
in  such  cases  it  would  not  be  justifiable  to  amputate. 
If  any  medicine  be  efficacious,  submurlas  hydrar- 
gyri,  with  opium,  is  that  under  which  I  have  seen 
the  majority  of  these  cases  recover:  and  opium 
should  also  be  applied  to  the  wound.* 

*  In  the  year  1819, 1  was  called  to  see  a  man  of  55  years  old, 
who  had  suffered  a  compound  fracture  of  the  tibia  and  fibula  by 
the  fiilling"  of  a  large  log-  across  his  leg.  The  bones  were  frac- 
tured about  three  inches  above  the  ankle-joint,  and  the  superior 
fractured  portion. of  the  tibia  projected  for  two  inches  and  a  half 
through  the  external  wound;  the  substance  of  the  muscles  and 
the  fibula  were  also  considerably  crushed.  The  patient  being  a 
servant  on  a  farm  and  his  chance  of  receiving  proper  diet  and 
attendance  being  very  doubtful,  together  with  his  age,  the  ex- 
tent of  the  injury,  and  the  extreme  warmth  of  the  weather,  de- 
termined US  to  amputate  the  limb,  for  which  immediate  pre- 
parations were  made.  The  owner  of  the  farm  accidentally  over- 
hearing the  consulting  surgeon,  (Dr  John  W.  Buckler,  now  a 
42 


330 


DISLOCATIONS  OP  THE  ANKLE-JOINT. 


(12.)  A  very  irritable  State  of  Constitution 
Will  sometimes  render  all  treatment  unavailing  to 
save  the  limb,  and  Avill  novi^  and  then  prove  destruc- 
tive, even  if  the  operation  be  performed.  There 
are  some  persons  originally  constituted  with  so  irri- 
table a  system,  that  the  slightest  injuries  will  destroy 
them.  There  is  a  much  greater  number  whose 
constitutions,  originally  good,  have  been  so  much 
injured  by  excess,  by  want  of  exercise,  by  over 
exertion  of  mind,  by  drinking  freely  of  spirits  and 
eating  but  little,  that  to  them  the  slightest  accidents 
prove  fatal. 

Case,  —  One  of  the  most  curious  examples  of  this 
kind  which  I  have  seen  was  in  a  man  who  worked 
at  Barclay's  Brewhouse,  in  the  Borough.  The  cir- 
cumstances were  these. 

On  Saturday  he  was  turning  a  cask,  and  a  splinter 
of  wood  entered  his  thumb,  which  he  immediately 
drew  out. 

On  Sunday  night  he  requested  his  wife  to  rise 
and  make  him  a  poultice  ;  for  his  thumb,  he  said, 
was  painful. 

On  Monday  he  sent  for  Mr  John  Kent,  surgeon  in 
the  Borough,  who  found  his  thumb  inflamed  and 
painful. 

most  respectable  and  distinguished  practitioner  in  Baltimore, 
Md)  speak  of  the  possibility  of  saving  such  a  limb  under  more 
favourable  circumstances,  overruled  our  decision  and  insisted 
that  we  should  attempt  to  save  the  limb.  In  consequence  the 
fracture  was  reduced,  ihe  limb  dressed  in  the  usual  manner,  and 
the  patient  carefully  attended  to  during  the  ensuing  fourteen 
days.  On  the  15th  day  from  the  accident  he  began  to  complain 
of  stiffness  of  the  lower  jaw,  and  on  the  16th,  notwithstanding 
all  the  remedies  exhibited,  he  expired  under  all  the  agonies  of 
con6rmed  tetanus.  Had  amputation  been  performed,  as  pro- 
posed, I  cannot  help  believing  that  the  life  of  this  man  would 
have  been  preserved.  J.  D.  G. 


DISLOCATIONS  OF  THE  ANKLE-JOINT.  331 


On  Tuesday  the  inflammation  had  extended  to  the 
hand  and  fingers. 

On  Wednesday  a  swelling  appeared  at  the  wrist, 
above  the  ligamentum  annulare  carpi,  and  the  man 
had  a  great  deal  of  irritative  fever,  and  was  obliged 
to  keep  his  bed. 

On  Thursday,  after  lecture,  Mr  Kent  came  to  me, 
requesting  I  would  see  this  man,  who  had  been  de- 
lirious during  the  night ;  his  arm  being  much  con- 
vulsed, and  his  body  becoming  generally  so.  I  went 
with  Mr  Kent,  and  feeling  the  thumb,  discovered  a 
fluctuation  in  the  theca.  I  put  a  lancet  into  the 
extremity  of  the  thumb,  and  a  considerable  quantity 
of  pus  issued.  Gratified  with  the  expectation  of 
his  being  relieved  by  the  discharge  of  the  matter,  I 
was  going  out  of  the  room  to  express  this  feeling  to 
his  friends,  when  I  heard  a  rustling  on  the  bed  be- 
hind me;  and  upon  Mr  Kent  and  myself  turning 
back,  we  saw  him  under  the  influence  of  a  convul- 
sive fit,  which  raised  him  in  his  bed,  and  in  which 
he  fell  back  and  expired. 

Living  as  these  persons  generally  do,  principally 
upon  porter  and  spirits,  they  have  constitutions 
which  render  them  the  worst  subjects  for  accident?. 

The  following  case  shows  the  violent  symptoms 
and  quick  dissolution  which  will,  from  the  same 
cause,  occasionally  ensue  in  compound  dislocation  of 
the  ankle. 

Case,  —  On  the  10th  of  June,  1809, 1  was  request- 
ed to  go  immediately  to  Gracechurch-street,  to  see 
a  Mr  Fenner,  who,  in  walking  opposite  to  the  City 
of  London  Tavern,  had  slipped  from  the  foot-way 
and  produced  a  compound  dislocation  of  the  ankle. 
The  tibia  projected  at  the  inner  ankle ;  the  fibula 
was  broken  ;  and  the  skin  was  tucked  in  under  the 
extremity  of  the  tibia. 


332 


DISLOCATIONS  OF   THE  ANKLE-JOINT. 


First: — I  immediately  procured  a  mattress  for 
him,  instead  of  a  feather  bed. 

Secondly  : —  A  many-tailed  bandage ;  /splints  lined 
with  wool  ;  and  pillows  and  tapes. 

Thirdly:  —  The  skin  was  divided,  and  the  bone 
reduced ;  but  it  was  much  opposed  by  violent  spasm 
of  the  muscles. 

Fourthly  :  —  The  edges  of  the  wound  were  close- 
ly adjusted. 

Fifthly:  —  The  bandage  and  splints  were  appli- 
ed; and  the  limb  was  placed  upon  pillows  on  its 
outer  side,  with  the  knee  bent. 

Sixthly:  —  Bled  to  145,  and  opium  given;  tinct. 
opii.  gtt.  XXX. 

June  11th.  His  night  had  been  restless;  his 
tongue  was  white;  liis  pulse  beat  110  strokes  in  a 
minute;  he  had  violent  pains  in  the  ankle,  and  had 
vomited.  Ordered  oleum  ricini,  as  his  bowels  had 
not  been  relieved.  Evening:  —  He  had  almost 
constant  spasms  of  the  muscles  of  the  leg;  he  had 
not  slept,  and  had  no  appetite,  The  oleum  ricini 
had  produced  four  evacuations. 

June  12th.  His  pulse  was  120;  his  tongue  more 
furred.  He  had  violent  and  very  frequent  spasms. 
He  had  nausea,  but  had  not  vomited  since  the  last 
report.  He  had  had  one  evacuation.  Blood  was 
extravasated  about  the  ankle  ;  and  a  sanious  serum 
was  discharged  from  the  wound.    Ordered  opium, 

June  13th.  Had  slept  three  hours.  There  was 
some  inflammation  about  the  wound,  and  swelling  of 
the  leg,  with  spasms,  but  they  were  less  violent  than 
yesterday.  A  poultice  was  applied  to  the  ankle,  and 
fomentations  ordered.  Pulse  120;  his  tongue  was 
very  much  furred.  Evening:  —  In  most  violent 
pain;  he  was  ordered  submurias  hydrargyri  five 
grains,  with  two  grains  of  opium,  and  the  saline  medir 
cine  with  antimony. 


DISLOCATIONS   OF  THE;   ANKLE-JOINT.  333 


June  J4th.  The  spasms  continued,  but  the  pain 
had  in  a  great  degree  ceased.  He  had  had  several 
evacuations,  but  had  been  delirious  during  the  night. 
The  limb  was  but  little  swollen;  the  foot  appeared 
slightly  inflamed,  but  there  was  no  healthy  discharge, 
nor  any  granulations  beginning  to  form.  The  former 
treatment  was  ordered  to  be  continued. 

June  l.Oth.  He  had  passed  a  bad  night,  having 
been  delirious  through  a  great  part  of  it.  He  had  a 
violent  spasm  in  the  limb  this  morning,  which  pro- 
duced a  slight  hasmorrhage,  which  was  stopped  by 
pressure.  His  leg  w^as  swollen,  and  the  wound  ap- 
peared to  be  without  action.  His  pulse  was  equal- 
ly quick,  and  he  took  no  nutriment. 

June  16th.  He  had  spasms  in  the  thigh  of  the 
same  side,  and  in  the  other  leg,  as  much  as  in  the 
injured  limb 5  in  other  respects  he  remained  the 
same. 

June  17th.  He  was  delirious  during  the  previous 
night,  and  bleeding  was  again  produced  by  the  vio- 
lence of  the  spasms.  His  pulse  was  considerably 
quicker  than  before. 

June  18th.  He  died  at  four  o'clock  in  the  after- 
noon. 

Corpulent  persons,  —  Persons  who  are  much  load- 
ed with  adeps  are  generally  very  irritable,  and  bear 
important  accidents  very  ill  ;  indeed  they  frequently 
perish,  whatever  plan  of  treatment  be  pursued  :  to 
this  statement,  however,  there  are  exceptions  in  those 
who,  though  corpulent,  are  still  in  the  habit  of  tak- 
ing much  exercise,  as  they  will  retain  some  vigour  of 
constitution ;  and  in  such  persons  the  limb  may  be 
attempted  to  be  saved,  as  in  the  case  described  by 
Mr  Abbott,  surgeon  at  Needham  Market ;  but  in 
those  who  have  become  extremely  fat,  and  who  have 
been  addicted  to  habits  of  indolence,  there  is  but  lit- 
tle chance  of  preserving  life  but  by  amputation. 


334 


DISLOCATIONS   OP  THE  ANKLE-JOINT. 


Invitation  to  correspondence  on  the  subject.  —  Having 
thus  endeavoured  to  explain  what  has  fallen  under 
my  own  observation,  and  what  I  have  been  able  to 
Jearn  from  others  upon  this  difficult  subject,  I  beg  to 
express  a  hope,  that  any  of  my  friends,  who  may 
have  had  cases  under  their  care  which  would  throw 
further  light  upon  the  subject,  will  have  the  kind- 
ness to  communicate  them  to  me,  whether  they  make 
for  or  against  the  advice  that  I  have  given,  as  I  have 
no  further  wish  but  that  all  the  points  respecting 
this  severe  accident  may  be  fully  elucidated  and  es- 
tablished ;  and  shall  only  add,  that  the  observations 
which  I  have  made  in  favour  of  saving  the  limb  in 
compound  dislocations  of  the  ankle-joint,  will  apply 
much  more  strongly  in  country  practice  than  in  that 
of  the  large  hospitals  in  London, 

The  Jlnhle  is  sometimes  dislocated  by  Ulceration, 

September  23rd,  1823.  With  Mr  Dixon,  surgeon 
of  Kennington,  I  visited  Mr  P.,  a  patient  of  his,  who 
had  a  dislocation  of  the  ankle  produced  by  ulcer- 
ation. An  ulcer  existed  at  the  inner  ankle,  which 
had  discharged  synovia.  The  ankle-joint  was  red 
and  greatly  swollen,  the  foot  drawn  outwards  by  the 
action  of  muscles,  and  the  internal  malleolus  thrown 
inwards  upon  the  astragalus.  The  tibial  arteries 
were  greatly  stretched;  and  the  fibula,  by  its  pres- 
sure on  the  malleolus  externus,  produced  consider- 
able and  constant  pain.  Mr  P.  is  a  very  old  man, 
and  dying  of  the  disease. 


FRACTURES     OF     THE     TIBIA  AND 
FIBULA    NEAR    THE  ANKLE-JOINT. 


Fracture  of  the  fibula.  —  The  fibula  is  frequently 
broken  from  two  to  three  inches  above  the  ankle- 
joint,  and  the  patient  instantly  becomes  conscious  of 
the  accident  by  feeling  a  snap  a  little  aboVe  the 
outer  ankle;  by  the  pain  which  he  suffers  in  his  at- 
tempt to  bear  upon  the  foot ;  by  his  inability  to 
place  his  foot  flat  upon  the  ground,  resting  it  rather 
on  the  inner  side  to  throw  the  bearing  of  the  body 
upon  the  tibia;  and  by  pain  and  a  sensation  of  mo- 
tion at  the  injured  part  when  the  foot  is  bent  or  ex- 
tended. The  surgeon  discovers  the  nature  of  the 
accident  by  rotating  the  foot  with  one  hand,  and  by 
grasping  the  lower  part  of  the  leg  with  the  other ; 
at  each  rotation  a  crepitus  is  generally  felt.  There 
is  also  frequently  an  inequality  of  the  bone  at  the 
broken  part,  which  assists  in  pointing  out  the  nature 
of  the  injury. 

Its  cause,  —  The  cause  of  this  injury  is  a  blow  upon 
the  inner  side  of  the  foot,  or  some  violence  which 
forces  it  outwards  against  the  lower  extremity  of 
the  fibula  ;  and  I  have  known  it  broken  by  distor- 
tion of  the  foot  inwards.  A  fall  laterally,  whilst  the 
foot  is  confined  in  a  deep  cleft,  produces  this  acci- 


336 


FRACTURES   OF  THE  ANKLE-JOINT. 


dent.  I  broke  my  right  fibula  by  falling  on  my  right 
side  whilst  my  right  foot  was  confined  between  two 
pieces  of  ice,  and  1  could  with  difficulty  support  my- 
self to  a  neighbouring  house  by  bearing  upon  the 
inner  side  of  my  foot.  I  went  home  in  a  carriage, 
and  every  jolt  of  it  gave  me  pain  at  the  fractured 
part  as  I  suspended  my  leg  upon  my  hand.  I  knew 
that  the  bone  was  broken  by  the  severe  snap  which 
I  felt  in  the  part  at  the  moment  of  the  accident. 

Its  treatment, — The  treatment  which  this  injury 
requires  is,  to  apply  a  many-tailed  bandage  upon  the 
limb,  and  to  keep  it  wet  with  a  lotion  of  spir.  vini* 
3  aquoe  3  v  ;  to  apply  a  splint,  with  a  foot-piece  on 
each  side,  padded  with  cushions  in  such  a  manner 
as  to  preserve  the  great  toe  in  a  line  with  the  pa- 
tella, an  invariable  rule  on  these  occasions;  and  to 
place  the  leg  upon  its  side  in  the  semiflexed  position, 
so  as  io  relax  the  muscles,  and  render  the  patient's 
position  as  easy  as  possible. 

Lameness  from  neglect,  —  A  want  of  attention  to 
the  treatment  of  this  accident  leads  to  permanent 
lameness.  Dr  Blair,  a  naval  physician  in  the  Ame- 
rican war,  informed  me  that  he  found  great  difficulty 
in  walking  the  streets  of  London  on  one  side  of  the 
way,  but  upon  the  other  he  walked  better  than  upon 
flat  ground;  and  when  I  remarked  his  lameness, and 
inquired  into  its  cause,  he  informed  me  it  had  arisen 
from  a  fracture  of  the  fibula,  which  happened  many 
years  ago  ;  and  to  which  not  having  applied  splints^ 
the  foot  became  twisted,  so  that  he  walked  better 
upon  an  inclined  plane  than  upon  flat  ground. 


FRACTURES  OF  THE  ANKLE-JOINT. 


337 


FRACTURES   OF  THE  TIBIA   AT  THE  ANKLE-JOINT. 

Fracture  of  the  tibia.  —  The  tibia  is  often  broken 
into  the  ankle-joint,  or  through  the  bone  a  little 
above  it;  and  these  fractures  pass  either  obliquely 
inwards,  or  obliquely  outwards  :  the  first  in  a  line 
from  the  usual  seat  of  fracture  of  the  fibula,  that 
is,  from  one  to  two  inches  above  the  external  mal- 
leolus to  the  inner  ankle  :  the  second  from  one  to 
two  indies  of  the  tibia  above  the  ankle,  downwards 
and  outwards  into  the  joint. 

Diagnosis. — Tfie  first  is  distinguished  by  crepi- 
tus at  the  ankle  when  the  foot  is  rotated,  bent,  or 
extended  ;  and  by  a  slight  inclination  of  the  foot 
outwards.  If  the  fracture  does  not  enter  the  joint, 
but  obliquely  crosses  the  tibia  above  it,  the  lower 
part  of  the  tibia  slightly  projects  over  the  malleolus 
internus. 

Treatment.  —  The  treatment  in  this  case  consists 
in  using  evaporating  lotions  ;  the  many-tailed  band- 
age ;  splints  with  a  foot  piece  to  each,  padded  so  as 
to  incline  the  foot  inwards,  and  to  bring  the  toe  into 
its  natural  line  with  the  patella,  which  is  easily  ef- 
fected with  the  splints  to  which  1  have  alluded. 

Obliquefiactures. — The  symptoms  of  the  oblique 
fracture  of  the  tibia  downwards  and  outwards  into 
the  joint  are,  as  in  the  former  case,  a  crepitus  upon 
rotation,  flexion  and  extension;  but  the  foot  is  slight- 
ly inclined  inwards,  and  the  malleolus  externus  pro- 
jects more  than  it  naturally  would.  The  same 
bandages  and  splints  are  to  be  used  as  in  the  former 
case  ;  and  the  position  in  both  these  accidents  should 
be  as  follows. 

Treatment.  —  The  leg  should  be  raised  so  as  to 
bend  and  elevate  the  knee  ;  and  the  limb  should 
rest  upon  the  gastrocnemius  muscle,  and  upon  the 
43 


338  FRACTURES  OF  THE  ANKLE-JOINT. 


heel.  The  splints  will  support  the  foot  on  each 
side,  and  the  leg  should  be  supported  hy  a  pillow, 
reaching  from  the  knee  to  beyond  the  foot,  secured 
by  tapes  around  it.  I  have  seen  both  these  cases 
do  well  when  the  patient  and  his  leg  rested  upon 
the  outer  side;  but  the  advantage  of  placing  the 
limb  upon  the  heel  is,  that  it  gives  the  surgeon  an 
opportunity  of  observing  the  least  deviation  in  the 
line  of  the  foot,  relatively  to  the  axis  of  the  leg; 
and  this  is  also  an  easier  position  to  the  patient. 

Dislocation  npivards  from  fracture. — The  outer 
portion  of  the  lower  extremity  of  the  tibia,  at  the 
part  at  which  it  joins  the  fibula,  is  sometimes  frac- 
tured and  split  off  from  the  shaft  of  the  bone  in 
juQiping  from  a  considerable  height  :  the  foot  then 
rises  between  the  tibia  and  fibula  ;  a  dislocation  of 
the  tibia  inwards  is  produced,  and  the  foot  is  elevat- 
ed between  the  two  malleoli.  The  treatment  re- 
quired in  this  case  is  the  same  as  in  the  dislocation 
inwards. 

Oblique  compound  fractures. — Oblique  compound 
fractures  into  the  ankle-joint  generally  do  well  if 
care  be  taken  to  produce  adhesion  of  the  wound, 
which  is  to  be  effected  by  applying  lint,  imbrued  in 
blood,  to  the  lacerated  skin,  and  by  leaving  it  there 
until  it  separates  spontaneously.  The  same  band- 
ages and  splints  are  required  as  in  simple  fractures, 
but  the  position  must  be  varied  according  to  thie  sit- 
uation of  the  wound.  Even  if  suppuration  occurs 
the  patient  will  generally  recover,  unless  he  be  much 
advanced  in  years. 

But  if,  with  compound  fracture  into  the  joint, 
there  be  much  comminution  of  bone,  and  haemorr- 
hagy  from  any  large  vessel,  it  will  be  proper  to 
amputate  immediately,  more  especially  if  the  pa- 
tient be  obliged  to  obtain  his  bread  by  his  labour; 
for  after  recovery,  under  great  comminution,  the 
limb  will  bear  but  slight  exerlion. 


DISLOCATION  OF  THE  TARSAL  BONES. 


SIMPLE    DISLOCATION    OF  THE  ASTRAGALUS. 

Junction  with  other  hones,  —  The  astragalus  is 
connected  above  and  on  each  side  with  the  tibia  and 
fibula  by  its  trochlea;  below  it  has  articulatory  sur- 
faces for  its  junction  with  the  os  calcis,  to  which  it 
is  united  bj  means  of  a  capsular  and  strong  interos- 
seous band  of  ligament ;  and  anteriorly  to  the  os 
naviculare,  by  a  capsular,  broad,  and  internal  lateral 
ligament.  A  simple  dislocation  of  the  astragalus 
sometimes,  though  rarely,  occurs ;  a  compound  lux- 
ation is  still  more  rare. 

Simple  dislocations.  —  A  simple  luxation  of  the 
astragalus  is  a  most  serious  accident,  being  very 
difficult  to  reduce  ;  and  should  the  reduction  not  be 
effected,  the  patient  is  ever  after  doomed  to  a  con- 
siderable degree  of  lameness. 

Case. — Being  sent  for  into  the  country  to  visit  a 
patient,  the  surgeon,  Mr  James,  of  Croydon,  whom 
I  met  there,  requested  me  to  see  a  gentleman  who 
had  a  dislocation  of  the  foot,  which  had  happen- 
ed several  weeks  before,  but  had  not  proceeded 
to  his  satisfaction.     Upon   examination,   I  found 


340 


DISLOCATIONS  OF  THE  TARSAL  BONES. 


the  astragalus  dislocated  outwards,  and  the  tibia 
broken  obliquely  at  the  inner  malleolus.  Every 
attempt  to  reduce  it  was  made  which  Mr  James, 
who  is  an  extremely  well  informed  man,  could  adopt ; 
five  persons  kept  up  a  continued  extension  when  the 
accident  first  happened,  but  without  eifect ;  the  pa- 
tient was  then  taken  home,  and  several  persons  were 
employed  in  extending  the  foot,  and  it  was  thought, 
after  a  time,  with  some  success;  but  the  reduction 
could  not,  by  all  their  efforts,  be  rendered  complete., 
as  the  astragalus  still  remained  projecting  upon  the 
upper  and  outer  part  of  the  foot.  The  extension 
could  not  be  carried  further;  the  integuments 
sloughed  from  that  which  had  been  already  made  ; 
and  the  wound  was  a  long  time  in  healing.  The  limb 
now  deviates  much  from  its  natural  shape;  the  toes 
are  turned  inwards  and  pointed  downwards  ;  there  is 
some  little  motion  at  the  ankle,  and  only  a  slight  de- 
gree of  it  betw^een  the  projecting  and  raised  astrag- 
alus and  the  other  bones  of  the  tarsus. 

This  accident,  then,  is  of  a  most  serious  nature; 
for  the  gentleman  in  question  had  placed  himself 
under  the  care  of  a  most  intelligent  and  persevering 
surgeon,  and  yet  the  attempts  made  at  reduction 
were  not  successful,  merely  from  the  nature  of  the 
accident,  and  not  from  any  fault  in  the  means  em- 
ployed. In  these  cases  the  use  of  pulleys  will  be 
required,  and  the  action  of  the  muscles  should  be 
lessened  by  tartarized  antimony.    (*See  Plate,) 

I  attended  the  following  cage  with  my  friends, 
Mr  West,  surgeon  of  Hammersmith,  and  Mr  Ireland, 
surgeon  in  Hart-street,  Bloomsbury.  It  is  highly 
interesting  and  instructive ;  and  shows  most  clearly 
the  necessity  that  surgeons  should  be  upon  their 
guard  in  amputating  limbs,  and  in  performing  opera- 
tions, as  the  resources  of  nature  are  sufficient,  under 
very  formidable  circumstances,  to  effect  restoration. 


DISLOCATIONS  OF  THE  TARSAL  BONES.  341 


Case.  —  On  July  the  24th,  1820,  Mr  Downes  had 
the  misfortnne  to  dislocate  the  astragalus  by  falling 
from  his  horse.  The  accident  happened  at  Kinsal 
Green,  about  six  miles  from  London  ;  and  Mr  West, 
surgeon  at  Hammersmith,  who  was  called  in  to  him, 
made  an  attempt  to  reduce  the  dislocation,  which 
could  not  be  effected.  The  patient  was  largely- 
bled;  the  limb  was  placed  in  splints;  Goulard's  lo- 
tion was  applied,  and  an  anodyne  given.  The  pa- 
tient felt  great  pain,  and  a  sense  of  pressure  against 
the  skin  and  ligaments,  on  the  evening  of  the  acci- 
dent. A  purge  was  directed  to  be  taken,  and  ano- 
dynes occasionally  in  saline  draughts. 

On  the  following  day,  the  2f)th,  Mr  Ireland,  who 
had  visited  Mr  Downes  the  evening  before,  called 
upon  me  and  requested  me  to  accompany  him  to  see 
the  patient,  and  to  meet  Mr  West.  When  I  exam- 
ined the  limb  I  found  the  astragalus  dislocated  for- 
wards and  inwards ;  the  fibula  appeared  to  be  broken 
a  liule  above  the  joint.  I  made  an  attempt  to  re- 
duce it,  but  found  the  bone  immovably  fixed  in  its 
new  situation,  projecting  so  as  to  make  the  nature 
of  the  case  perfectly  clear,  and  bearing  so  strongly 
against  the  skiji  that  a  slight  incision  would  have 
exposed  it.  My  first  impression  was,  that  I  ought 
to  dissect  away  the  astragalus;  but  avvare  of  the 
resources  of  nature  in  accommodating  parts  under 
luxations,  and  in  restoring  the  limb  to  usefulness,  I 
observed  to  Mr  West,  and  to  Mr  Ireland,  that  I 
would  not  operate,  and  that  perhaps  the  skin  might 
give  way,  and  the  bone  become  exposed,  when  we 
should  be  justified  in  removing  it.  The  previous 
treatment  was  continued. 

On  the  2lith  he  had  some  irritative  fever,  when 
the  saline  medicine  with  antimony  was  given. 

On  the  28th  there  was  considerable  local  irrita- 
tion, and  leeches  were  applied. 


342 


DISLOCATIONS  OF  THE  TARSAL-BONES. 


On  the  29th  the  leeches  were  repeated  and  the 
lotion  continued. 

On  August  the  10th  the  skin  began  to  be  disposed 
to  slough,  opposite  the  projection  of  the  astragalus 
at  the  inner  ankle. 

On  the  14th,  fomentations  and  a  vest  poultice 
were  directed  to  be  applied,  and  bark  and  wine 
were  given. 

On  the  16th  the  skin  sloughed. 

On  the  20th  there  was  a  great  discharge  of  pus, 
and  the  astragalus  became  exposed.  The  same 
means  were  continued;  and  the  inflammation  and 
discharge  gradually  lessening,  the  wound  was  dressed 
with  lint  and  adhesive  plaster. 

The  astragalus  gradually  became  dislodged ;  the 
ligament  sloughing  or  ulcerating.  In  September, 
the  patient  was  able  to  be  removed  to  London. 

On  October  the  5th,  1820,  1  again  saw  him,  and 
finding  the  astragalus  very  loose,  removed  it  with 
forceps,  dividing  only  some  slight  ligamentous  adhe- 
sions. The  bleeding  was  trifling,  and  was  suppressed 
by  the  application  of  lint  alone. 

In  December  some  slight  exfoliations  occurred, 
which  produced  pain  and  inflammation ;  but  at  the 
end  of  the  month  he  began  to  walk. 

After  the  astragalus  was  removed,  soap  plaster 
was  applied  ;  and  Mr  Downes  gradually  recovered 
his  strength,  and  was  able  to  walk  without  the  aid 
of  a  stick. 

In  October,  1821,  he  had  slight  motion  at  the 
ankle,  which  has  been  gradually  increasing.  (See 
Plate.) 


DISLOCATIONS  OF  THE  TARSAL  BONES.  343 


COMPOUND  DISLOCATION    OF  THE  ASTRAGALUS. 

Case.  —  In  the  first  case  of  this  accident  which  I 
had  an  opportunity  of  witnessing,  the  astragalus  was 
thrown  inwards  and  forwards  upon  the  os  naviculare; 
and  when  I  afterwards  saw  the  limb  upon  the  table 
of  the  dissecting-room,  it  having  been  removed  by 
amputation,  I  exclaimed, surely  that  limb  might  have 
been  saved. 

Case.  —  In  the  case  of  which  an  account  was  sent 
me  by  Dr  Lynn,  of  Bury  St  Edmunds,  it  will  be 
seen  that  the  discharge  of  the  astragalus,  in  a  com- 
pound dislocation  of  the  ankle-joint,  did  not  prevent 
the  patient's  recovery;  for  he  says,  'In  five  weeks  a 
portion  of  the  astragalus  separated,  and  another 
piece  a  week  afterwards,  which,  when  joined,  formed 
the  ball  of  that  bone.' 

Case.  —  Mr  Trye,  of  Gloucester,  had  also  under 
his  care  a  case  of  compound  luxation  of  the  astraga- 
lus, in  which  he  cut  out  the  luxated  bone,  and  the 
patient  had  a  good  recovery,  with  a  tolerably  useful 
foot. 

The  following  case  was  under  the  care  of  Mr 
Henry  Cline,  in  St  Thomas's  Hospital. 

Case. —  Martin  Bentley,  aged  thirty  years,  was 
admitted  into  St  Thomas's  Hospital  at  twelve  o'  clock 
at  noon,  on  June  21st,  1815.  He  had  just  before 
been  overpowered  by  some  stones  which  he  was 
endeavouring  to  sling  into  a  ship's  hold,  by  which 
he  was  knocked  down,  and  which  fell  upon  him, 
occasioning  a  compound  fracture  of  the  tibia  and 
fibula  of  the  left  leg,  near  the  middle,  with  a  dis- 
location of  the  astragalus  of  the  other  foot  from 
the  other  bones  of  the  tarsus. 

As  there  was  much  laceration  of  the  skin  and 


344  DISLOCATIONS  OF  THE  TARSAL  BONES. 


muscles,  Mr  H.  Cline  thought  it  right  to  amputate 
the  limb  below  the  knee,  which  was  done  about 
three  hours  alter  his  admission.  He  complain- 
ed of  much  pain  during  the  operation,  with  fre- 
quent jerking  of  the  limb  :  the  muscles  were  ex- 
tremely rigid  :  five  ligatures  were  applied,  and  the 
wound  was  dressed  as  usual. 

The  other  foot  presented  the  following  appear- 
ance:  The  protuberance  of  the  os  calcis  had  nearly 
disappeared;  but.  this  bone  projected  laterally,  and 
on  the  outer  side  mucli  beyond  the  outer  malleolus, 
just  under  which,  however,  was  a  remarkable  de- 
pression. Immediately  below  the  inner  malleolus 
was  a  remarkable  and  unnatural  projection.  The 
whole  foot  seemed  somewhat  displaced  outwards, 
the  toes  turning  out.  The  astragalus  must  here 
have  been  dislocated  from  both  the  navicular  bone 
and  OS  calcis,  and  thrown  inwards,  so  as  to  have  its 
inferior  articulatory  surfaces  for  the  os  calcis  resting 
on  the  inner  edge  of  that  bone. 

After  the  am[)utation,  the  dislocation  in  the  other 
foot  was  reduced  by  fixing  the  knee,  having  the 
thigh  bent  at  right  angles  with  the  body  ;  then  lay- 
ing hold  of  the  metatarsus  and  protuberance  of  the 
OS  calcis,  and  drawing  the  foot  gently  and  directly 
from  the  leg.  Duririg  this  exterision,  Mr  H.  Cline 
put  his  knee  against  the  outside  of  the  joint,  and 
the  foot  being  pressed  against  it,  the  os  calcis  and 
navicular  bones  slipped  into  the  place,  carrying  with 
them  the  rest  of  the  foot,  and  the  deformity  disap- 
peared. He  was  then  carried  to  bed,  and  an  out- 
side splint  was  applied,  being  well  padded,  and 
secured  by  tapes;  and  the  leg,  as  far  as  could  be, 
was  placed  on  the  outer  side.  Goulard's  wash  was 
applied. 

June  24,    The  lead  wash  was  left  off,  and  soap 
cerate  put  on  the  right  leg. 


DISLOCATIONS  OF  THE  TARSAL  BONES.  345 


June  25.  The  cerate  has  blistered  his  leg  in 
several  places,  and  he  complains  of  more  pain  than 
yesterday  at  his  ankle. 

June  28.  The  stump,  which  is  going  on  well, 
dressed  to-day;  one  ligature  came  away.  The  pain 
in  his  ankle  has  subsided. 

July  1.  Complains  of  uneasiness  about  the  epi- 
gastrium, and  sickness;  pulse  112  and  hard  ;.  3  vviij. 
blood  taken  from  the  arm. 

July  2.     All  untoward  symptoms  have  disap- 

July  4.  Two  ligatures  came  away.  A  sore, 
which  is  the  effect  of  the  soap  cerate,  on  the  inner 
malleolus,  is  dressed  with  wax  and  oiL  He  is  now 
capable  of  raising  his  leg,  which,  however,  is  be- 
numbed. 

July  13.  The  ligatures  not  appearing  disposed 
to  come  away,  a  piece  of  whale-bone  was  fixed  on 
the  side  of  the  stump,  to  which  they  were  attached, 
and  so  kept  constantly  tight.  Was  put  on  the  hos- 
pital diet  to-day;  had  previously  been  on  milk  diet. 

July  19,  One  of  the  ligatures  was  removed  with 
some  difficulty  by  Mr  H.  Cline  ;  the  other  came 
away  easily  on  the  following  day. 

August  7.  The  man  walked  in  the  square  for 
the  first  time  since  the  accident 

August  26.  He  went  out,  and  was  capable  of 
walking  tolerably  well. 

I  conversed  with  Mr  Henry  Cline  on  the  subject 
of  these  accidents  ;  and  Mr  Green,  who  saw  the 
preceding  case  in  the  commencement,  sent  me  the 
following  letter  respecting  it. 

Lincoln^  Inn  Fields ;  Jlugust  19th,  1819. 
My  dear  Sir:  —  In  the  notes  of  Martin  Benlley's 
case,  which  I  made  at  the  time  when  he  was  under 
44 


peared 


346 


DISLOCATIONS  OF  THE  TARSAL  BONES. 


Mr  Henry  Cline's  care  in  St  Thomas's  Hospital,  1 
find  it  stated  that  the  right  astragaUis  was  dislocated 
inwards;  that  is,  that  the  os  calcis,  with  the  rest  of 
the  foot,  was  thrown  outwards  :  and  the  description 
which  I  have  there  given  ol'  the  appearance  is,  that 
the  whole  foot  seemed  to  be  somewhat  displaced 
outwards ;  that  the  os  calcis  projected  laterally 
much  beyond  the  outer  malleolus,  whilst  the  protu- 
berance of  that  bone  had  nearly  disappeared;  and 
that,  in  consequence  of  the  astragalus  retaining  its 
situation,  there  was  a  remarkable  depression  be- 
neath the  outer  malleolus,  between  it  and  the  dis- 
placed OS  calcis;  and  as  remarkable  a  projection, 
produced  by  the  astra2:a!u3,  below  the  inner  malleo- 
lus. This  accident,  which  was  accompanied  with  a 
compound  fracture  of  the  opposite  leg,  had  been 
produced  by  the  fall  of  several  large  stones.  The 
reduction  of  the  dislocation  was  effected  without 
difficulty.  First,  by  fixing  the  knee;  then  by  mak- 
ing extension  of  the  foot,  gently  and  directly  from 
the  leg,  by  laying  hold  of  the  heel  with  one  hand, 
and  placing  the  other  on  the  dorsum  of  the  foot ; 
and,  lastly,  by  pressing  the  foot  inwards,  whilst  a 
counter  pressure  was  made  with  the  knee  upon  the 
lower  extremity  of  the  tibia  on  the  opposite  side. 
The  foot  was  afterwards  placed  on  its  outside,  and 
secured  upon  a  well  padded  splint. 

In  the  case  of  compound  luxation  of  the  tarsal 
bones,  likewise  under  the  care  of  Mr  Henry  Cline, 
it  appears,  according  to  my  notes,  that  the  astraga- 
lus was  displaced  outwards;  that  is,  that  the  other 
tarsal  bones  were  thrown  inwards.  I  find  that  the 
appearances  are  described  to  have  been,  that  the 
foot  was  turned  considerably  inwards;  that  the 
articular  surface  on  the  head  of  the  astragalus, 
which  is  received  into  the  cup  of  the  navicular  bone, 
was  exposed  through  an  extensive,  but  tolerably 


DISLOCATIONS   OF  THE  TARSAL  BONES. 


347 


clean  cut  through  the  integuments;  and  that  the 
articulating  surface  of  the  os  calcis,  with  the  astra- 
galus, might  also  be  perceived  on  the  outer  side. 
The  accident  was  said  to  have  been  occasioned  by 
the  fall  of  a  heavy  stone,  which  had  struck  his  heel. 

Reduction  of  the  dislocated  parts  was  accomplish- 
ed, first,  by  bending  the  leg  so  as  to  relax  the  mus- 
cles, and  then  by  extending  the  foot  in  the  manner 
described  in  the  former  case,  rotating  it  at  the  same 
time  outwards. 

The  patient  was  a  robust,  but  not  corpulent,  la- 
bouring man,  between  forty^  and  fifty  years  of  age. 
He  stated  that  he  had  been  in  the  habit  of  drinking, 
and  that  he  was  occasionally  subject  to  gout. 

You  have  already,  I  believe,  been  made  acquaint- 
ed with  the  particulars  of  the  progress  of  the  case, 
of  which  the  most  remarkable  features  appeared  to 
be,  that  the  primary  constitutional  irritation  was 
violent,  but  of  short  duration ;  and  that  his  recovery 
was  retarded  by  extensive  erysipelatous  inflamma- 
tion, which  terminated  in  sloughing,  and  by  the  for- 
mation of  matter  at  the  part,  accompanied  by  irri- 
tative fever  and  loss  of  strength;  but  that  his  re- 
covery, although  tedious,  was  complete. 

Joseph  Henry  Green. 


For  the  following  case  I  am  also  indebted  to  Mr 
Green,  who  is  an  admirable  anatomist,  and  an  excel- 
lent surgeon. 

Case.  —  Thomas  Toms,  twenty-three  years  of  age, 
was  admitted  into  St  Thomas's  Hospital  on  July  the 
14th,  1820.  He  had  fallen,  whilst  engaged  in  his 
business,  that  of  a  bricklayer,  from  a  three  story 
scaffold  ;  and  his  descent  had  been  arrested  by  his 
foot  catching  between  the  spikes  of  an  iron  railing, 
from  which  he  hung  with  his  head  nearly  touching 


348 


DISLOCATIONS  OF  THE  TARSAL  BONES. 


the  ground.  A  wound  was  found  extending  beneath 
the  inner  malleohis  of  the  left  leg;  and  the  head  of 
the  astragalus,  which  was  torn  from  the  articulator^ 
surface  of  the  os  naviculare,  protruded  through  the 
divided  integuments.  Part  of  the  articulatorj  carti- 
lage of  the  displaced  bone  had  been  separated,  and 
the  bone  was  i^jirt  by  the  edges  of  the  wounded  skin, 
which  was  puckered  under  it.  The  tendons  of  the 
tibialis  anticus  and  of  the  flexor  muscles  were  tightly 
stretched,  and  the  foot  was  turned  rather  upwards 
and  outwards.  Further  examination  showed  that 
the  posterior  tibial  artery  was  torn  through,  and  that 
the  accompanying  nerve  was  partially  lacerated. 

An  attempt  was  made  to  reduce  the  luxated  as- 
tragalus by  fixing  the  knee,  after  having  bent  the 
leg  upon  the  thigh,  and  by  making  extension  of  the 
foot  directly  from  the  leg,  laying  hold  of  the  heel 
with  one  hand,  and  placing  the  other  on  the  dorsum 
of  the  foot.  This,  however,  failed  ;  and  as  it  ap- 
peared that  the  skin,  which  firmly  embraced  the 
bone  beneath,  prevented  the  replacement,  it  was 
divided,  and  the  extension  renewed,  but  with  the 
same  unsuccessful  result.  This  difficulty  seemed  to 
arise  from  the  small  size  of  the  wound  in  the  capsule 
of  the  joint,  and  from  tightness  with  which  the  bone 
was  held  by  the  tendons. 

Fearing  then  that  the  reduction  was  impractica- 
ble, I  was  led  to  consider  whether  the  amputation 
of  the  leg  ought  not  to  be  proposed  ;  but  Sir  Astley 
Cooper  happening  to  be  in  the  hospital,  I  requested 
him  to  see  the  case,  and  after  a  careful  examination 
of  the  injured  limb,  he  suggested  that  the  astragalus 
might  be  removed.  I  concurred,  of  course,  in  this 
proposal,  as  it  attorded  a  probability  of  saving  the 
limb,  and  I  proceeded  accordingly  to  perform  the 
operation.  I  first  applied  a  ligature  on  the  posterior 
tibial  artery,  which,  however,  had  not  bled,  the  ori- 


DISLOCATIONS  OP  THE  TARSAL  BONES.  349 


fice  being  so  contracted  that  a  pin  could  not  hare 
been  introduced.  I  then  cautiously  used  a  scalpel, 
detached  the  ligaments  by  which  the  astragalus  is 
connected  with  the  bones  of  the  leg  and  tarsus,  and 
found  no  considerable  difficulty  in  removing  the  bone. 
The  parts  were  then  readily  brought  into  apposi- 
tion, and  the  wound  was  closed  with  straps  of  adhe- 
sive plaster.  The  leg  was  placed  on  its  outside, 
resting  on  a  well  padded  splint,  with  a  foot-piece; 
the  foot  was  supported  above  the  level  of  the  knee, 
and  the  constant  use  of  an  evaporating  lotion  was 
ordered. 

In  the  evening  of  the  same  day  slight  fever  had 
come  on,  but  the  limb  was  tolerably  easy  ;  and  the 
patient  had  an  evacuation  of  the  bowels. 

The  next  day  the  febrile  symptoms  had  increas- 
ed. His  pulse  was  fuller  and  quicker,  the  skin  was 
hot  and  dry,  the  tongue  furred,  and  thirst  consider- 
able ;  but  he  had  slept  two  or  three  hours  during 
the  night,  and  the  injured  part  was  free  from  pain. 
I  ordered  some  febrifuge  medicine,  and  directed 
thait  his  diet  should  be  low,  and  that  the  apartment 
should  be  kept  well  ventilated. 

On  the  third  day  the  fever  was  slightly  increased. 
He  complained  of  pain  at  the  ankle,  which  exhibited 
marks  of  inflammation,  and  he  had  had  no  stool. 
Sulphate  of  magnesia  in  the  infusion  of  roses  was 
ordered  in  repeated  doses,  until  the  bowels  should 
be  affected. 

At  my  visit  on  the  fourth  day,  I  learnt  that  after 
having  taken  five  doses  of  the  purgative  medicine, 
two  copious  evacuations  had  been  produced.  The 
fever  still  continued,  but  his  tongue  was  cleaner  and 
moister.  It  was  now  found  necessary  to  loosen  the 
sphnt-tapes,  as  the  leg  had  become  considerably 
swollen.    Some  discharge  of  pus  had  taken  place 


350  DISLOCATIONS   OF    THE  TARSAL  BONES. 


from  the  wound,  and  the  pain  complained  of  the  day 
before  had  subsided^ 

On  the  fifth  day  1  found  that  he  had  passed  a 
good  night,  and  the  fever  was  diminished  ;  but  he 
complained  of  a  sore  throat,  and  had  had  a  sh'ght 


shivering. 


On  the  sixth  day  I  learnt  that  he  had  passed  a 
sleepless  night  in  consequence  of  pain  in  the  foot 
and  leg,  and  that  his  head  had  been  somewhat  af- 
fected. The  pain  in  the  limb  had,  however,  subsid- 
ed; and  there  was  a  copious  discharge  frorn  the 
wound. 

On  the  eighth  day  the  fever  seemed  to  be  abated; 
the  pulse  was  tranquil,  and  was  not  more  than  86, 
and  his  bowels  were  open.  The  dressings  were  now 
removed,  and  the  ligature  on  the  artery  came  away. 
The  wound  had  a  healthy  granulating  appearance. 
He  was  allowed  to  take  some  animal  food. 

He  continued  mending  till  July  the  26th.  His 
sleep  had  been  sound  and  refreshing;  he  was  free 
from  fever,  and  from  pain  at  the  injured  part,  and 
his  appetite  was  improved.  But  on  this  day  it  was 
found  necessary  to  alter  the  position  of  the  leg,  by 
lowering  the  foot,  in  order  to  favour  the  escape  of 
matter  which  collected  in  a  sinus,  extending  about 
a  third  of  the  leg  upwards,  behind  the  inner  mal- 
leolus. 

On  July  the  29th  he  began  to  complain  of  pain  in 
the  leg,  and  lie  had  some  symptoms  of  constitutional 
disturbance.  These  unpleasant  effects  were  produced 
by  the  formation  of  an  abscess,  which  was  opened 
on  the  1st  of  August,  and  from  which  about  six 
ounces  of  pus  was  discharged.  He  became  after 
this  tranquil  and  easy,  and  the  discharge  of  matter 
gradually  decreased. 

On  August  the  10th  I  ventured  to  have  him  re- 
moved into  another  bed,  but  without  disturbing  the 


DISLOCATIONS   OP  THE  TARSAL  BONES.  351 


splints  or  pillows.  The  wound  at  the  ankle  was 
now  filled  with  granulations,  and  had  in  part  cica- 
trized. 

On  August  the  25th  his  health  had  become  again 
•deranged.  His  skin  was  hot,  his  countenance  flushed, 
and  he  complained  of  a  good  deal  of  pain  at  the 
outer  ankle,  where  it  rested  on  the  splint.  In  order 
to  prevent  this  inconvenience  the  leg  was  placed  in 
a  fracture  box  upon  the  heel,  and  a  poultice  was 
applied  to  the  ankle.  On  the  following  day  it  was 
evident  that  matter  had  formed  at  the  part,  and  an 
opening  was  therefore  made,  by  which  about  four 
ounces  of  pus  was  discharged. 

During  the  ensuing  week  a  discharge  again  took 
place  from  the  original  wound.  This  flow  of  matter 
was  copious,  a  considerable  quantity  being  furnished 
from  a  sinus  extending  to  the  calf  of  the  leg,  and  it 
continued  till  September  the  7th.  During  this 
period  his  leg  became  cedematous,  his  appetite  de- 
clined, and  he  was  subject  to  slight  hectic  fever. 

Subsequently  to  this  date  he  rapidly  improved: 
the  oedema  of  the  leg  subsided,  the  discharge  lessen- 
ed, and  the  wound  assumed  a  healthy  appearance. 
He  continued  to  mend  till  September  the  22nd, 
when  we  were  again  troubled  with  the  formation  of 
one  small  abscess  on  the  inside  of  the  leg,  and  of 
another  just  below  the  calf  of  the  leg.  These  were 
opened,  and  the  discharge  of  matter  gradually  sub- 
sided. 

In  the  .beginning  of  October  the  quantity  of  pu- 
rulent discharge  was  trifling.  He  was  now  allowed 
to  sit  up,  and  straps  of  soap  cerate  only  were  applied, 
with  a  roller. 

On  October  the  25th  the  discharge  had  entirely 
ceased.  The  parts  about  the  joint  were  quite  sound, 
and  pressure  produced  no  inconvenience.  He  was 
capable  at  this  time  of  performing  to  a  considerable 


352 


DISLOCATIONS  OF  THE  TARSAL  BONES. 


degree  the  flexion  of  the  foot  on  the  leg,  but  could 
not  extend  it. 

He  began  now  to  walk  a  little  with  the  aid  of 
crutches;  and  continuing  to  gain  health  and  strength, 
he  was  discharged  from  the  Hospital  on  November 
2nd. 

He  has  since  resumed  his  business,  and  performs 
his  duties  without  inconvenience. 

J.  H.  Green. 


DISLOCATION  OP  THE  OS  CALCIS  AND  ASTRAGALUS. 

The  five  anterior  bones  of  the  tarsus  are  some- 
times dislocated  from  the  os  calcis  and  astragalus. 
There  is  a  joint  placed  transversely  between  the  os 
calcis  and  astragalus,  and  the  os  naviculare  and  os 
cuboides ;  and  this  joint  is  sometimes,  but  rarely, 
luxated  by  very  heavy  weights  falling  upon  the  foot, 
of  which  the  following  is  an  example. 

Simple  Dislocation, 
Case,  —  A  man  Avorking  at  the  Southwark  Bridge 
had  the  misfortune  to  have  a  stone  of  great  weight 
glide  gradually  on  his  foot :  he  was  almost  irrjmedi- 
ately  brought  to  Guy's  Hospital,  and  the  following 
were  the  appearances  of  the  limb.  The  os  calcis 
and  the  astragalus  remained  in  their  natural  situa- 
tions, but  the  fore  part  of  the  foot  was  turned  in- 
wards upon  the  bones.  When  examined  by  the 
students  the  appearance  was  so  precisely  like  that  of 
a  club  foot^  that  they  could  not  at  first  believe  that 
it  was  not  a  natural  defect  of  that  kind:  but  upon 
the  assurance  of  the  man  that  previously  to  the  ac- 
cident his  foot  was  not  distorted,  an  extension  was 
made  by  fixing  the  leg  and  the  heel;  the  fore  part 


DISLOCATIONS   OF   THE   TARSAL   BONES.  353 


of  the  foot  was  then  drawn  outwards,  and  thus  the 
reduction  was  effected.  This  person  was  discharged 
from  the  hospital  in  five  weeks,  having  the  complete 
use  of  his  foot. 

Compound  Dislocation, 

The  following  interesting  case  was  under  the  care 
of  Mr  Henrj  Cline  ;  and  for  the  particulars  I  am 
indebted  to  his  apprentice,  Mr  South. 

Case.  —  Thomas  Gilmore,  an  Irish  labourer,  aged 
forty-five  years,  was  admitted,  under  Mr  H.  Cline, 
into  St  Thomas's  Hospital,  about  eleven  o'clock  on 
the  morning  of  March  28th,  1815.  Whilst  walking 
at  the  New  Custom  House  this  morning,  he  received 
a  blow  on  the  heel  from  the  falling  of*  a  stone  (said 
to  be  half  a  ton  weight),  which  made  a  wound  on 
the  fore  part  of  the  ankle-joint,  and  dislocated  the 
astragalus. 

The  parts  were  in  the  following  state: — A 
wound  extended  from  opposite  the  middle  of  the 
base  of  the  tibia,  round  the  upper  part  of  the  instep, 
to  the  external  malleolus,  which  exposed  the  articu- 
lating surface  of  the  astragalus  with  the  navicular 
bone  on  the  fore  part,  as  well  as  that  with  the  os 
calcis  on  the  outside;  from  both  which  bones  the 
astragalus  was  displaced  :  its  connexion  with  the 
tibia  and  fibula,  however,  was  undisturbed.  The 
tuberosity  of  the  os  calcis  projected  outwards,  but 
the  rest  of  the  foot  turned  in,  so  that  the  toes  point- 
ed much  inwards,  towards  the  opposite  foot. 

The  reduction  was  effected  by  extending  the  foot, 
and  rotating  it  outwards  ;  the  wound  was  brought 
together  with  straps  of  adhesive  plaster;  the  leg 
was  covered  with  soap  plaster  and  put  in  a  fracture 
box,  on  the  heel;  the  partj  were  kept  uncovered, 
and  a  slight  hasmorrhage  supervening,  linen  rags, 
dipped  in  cold  water,  were  applied. 
45 


354 


DISLOCATIONS   OF    1  HE   TARSAL  BONES. 


He  was  a  robust  man,  had  been  in  the  habit  of 
drinking,  and  sajs  he  has  been  subject  to  the  gout. 

March  29.  Had  not  slept  much,  as,  on  falling 
asleejD,  spasm  was  produced  ;  pulse  about  80;  skin 
cool;  he  has  taken  the  sulphate  of  magnesia,  which 
has  produced  two  evacuations.  The  part  is  not 
tumefied,  but  has  been  painful. 

March  30.  Has  passed  a  very  restless  night, 
having  been  delirious.  Pulse  120  ;  skin  hot  and  dry; 
fauces  parched.  Does  not  now  seem  quite  clear  in 
intellect.  This  morning  he  has  had  more  than  one 
rigor.  A  dose  of  sulphate  of  magnesia,  with  in- 
fusion of  senna,  had  procured  three  loose,  but 
healthy  stools.  The  part  has  become  more  swollen 
and  painful.  Ordered  fever  mixture,  with  ten  drops 
of  antimonial  wine,  every  six  hours.  In  the  afternoon 
he  had  three  more  stools. 

March  31.  Is  still  delirious,  and  did  not  sleep  last 
night.  Skin  very  hot  and  dry ;  mouth  parched ; 
pulse  about  112.  Has  had  two  stools  this  morning, 
without  medicine.  The  rigors  still  continue  occa- 
sionally, and  he  is  also  affected  with  tremors.  The 
inflammation  is  extending  up  the  leg,  and  a  bruise 
which  he  received  on  the  same  leg  is  now  ulcerating, 
to  which  a  dressing  of  wax  and  oil  is  applied. 

April  1.  Has  been  less  delirious  than  on  the 
two  former  nights.  Pulse  122;  tongue  cleaner ;  no 
stools. 

April  2.  Has  slept  better  than  on  the  previous 
nights.  Is  not  at  all  delirious.  Pulse  96  and  soft ; 
skin  moist,  and  he  has  perspired  freely;  no  stools; 
urine  in  large  quantity,  but  said  to  be  high-coloured. 
The  tremors  have  in  a  great  measure  left  him, 
and  he  feels  altogether  comfortable,  except  that 
there  is  a  considerable  degree  of  pain  in  the  in- 
jured part,  which  he  ascribes  to  a  rheumatic  affec- 
tion to  which  he  has  been  subject.     There  is  a 


DISLOCATIONS   OF   THE   TARSAL  BONES.  355 

slight  erysipelatous  inflammation  of  the  leg,  with 
some  oedema. 

April  3.  Has  passed  a  tolerably  good  night ;  is 
sensible;  pulse  100;  bowels  costive;  the  ankle 
easy. 

April  4.  Pulse  96 ;  skin  moist ;  has  had  two 
stools.  The  erysipelatous  inflammation  has  extend- 
ed rather  above  the  inlernal  condyle  of  the  os  fe- 
moris,  and  small  yellow  vesicles  have  formed;  this 
seems  to  have  proceeded  from  the  bruise  on  the 
calf  of  the  leg,  which  has  now  gone  into  a  state  of 
superficial  ulceration.  Soap  cerate  was  applied  to 
this  wound,  and  the  spirit  lotion  on  the  limb,  as  far 
as  the  inflammation  extended.  The  wound  on  the 
ankle  Avas  dressed  for  the  first  time  today;  the  liga- 
ments appear  to  be  sloughing;  the  strapping  was 
left  off,  and  wax  and  oil  dressing  was  applied. 

In  the  afternoon  his  pulse  was  104;  seems  rest- 
less, and  says  his  head  feels  rather  light:  had  an- 
other stool  towards  evening. 

April  5.  Has  been  delirious  all  night ;  skin  hot 
and  dry;  pulse  108,  and  weak;  these  symptoms 
indicate  a  fever  of  a  different  kind  from  the  preced- 
ing, viz  :  secondary,  and  sympathetic,  with  the  ery- 
sipelas :  the  wound  at  the  ankle  is  granulating,  and 
secreting  healthy  pus;  that  on  the  leg  is  very  pain- 
ful, and  has  assumed  a  sloughy  appearance.  Ordered 
decoction  of  bark  every  four  hours,  with  opium,  if 
diarrhoea  is  produced. 

April  6.  Is  delirious;  pulse  100  and  weak;  skin 
perspirable;  has  had  two  stools;  the  inflammation 
extends  nearly  to  the  groin ;  and  at  one  part  of  the 
thigh,  where  the  cradle  has  accidentally  pressed  the 
skin,  it  seems  as  if  it  would  slough  ;  takes  a  grain  of 
opium  twice  a  day, 

April  7.    Slept  pretty  well  ;  wanders  ;  pulse  1  10. 


35G 


DlSLOCATIOxNS   OF  THE  TARSAL  BONES. 


but  strong;  skin  not  very  hot  ;  no  stool;  much  pus 
is  discharged  from  the  wound  at  the  ankle. 

April  8.  Has  been  restless  during  the  night; 
pulse  96,  with  some  power;  skin  moderately  hot; 
is  thirsty;  delirious;  tongue  rather  foul;  bowels 
costive  ;  his  urine,  of  which  he  still  voids  a  great 
quantity,  scalds  him ;  pus  is  forming  in  different 
parts  of  the  limb;  and  the  inflammation  on  the 
thigh  seems  now  to  be  stationary. 

April  10.  Slept  well;  is  not  delirious;  pulse  96, 
not  weak;  skin  not  very  hot;  has  appetite;  the  part 
is  painful,  but  the  inflammation  on  the  thigh  is  con- 
siderably diminished,  and  the  sloughs  are  circum- 
scribed ;  pulse  healthy.  A  few  days  since  he  was 
ordered  a  pint  of  porter  daily,  which  is  now  increas- 
ed to  two  pints. 

April  11.  Says  he  occasionally  wanders;  pulse 
100,  rather  weak;  appetite  tolerably  good;  skin 
moist ;  has  had  stools. 

April  12.  The  inflammation  is  less ;  the  opium 
which  he  takes  procures  him  good  nights  ;  the  wound 
at  the  ankle  is  much  the  same  ;  the  sloughing  sore 
on  the  calf  of  the  leg  better;  to-day  he  was  moved 
into  a  clean  bed,  and  the  limb  was  placed  on  the 
outer  side,  as  he  wishes  to  lie  on  his  side. 

April  13.  Is  composed;  pulse  98;  skin  cool; 
feels  weak;  has  not  much  appetite,  but  likes  his 
porter;  the  sloughs  on  the  leg  separate  slowly. 

April  14.  The  limb  was  returned  to  its  old 
position  on  the  heel,  as  he  was  less  comfortable 
when  it  was  placed  on  the  side. 

April  17.  Pulse  92,  and  weak;  has  little  or  no 
appetite  ;  the  bark  and  opium  were  left  off  to-day, 
as  they  seem  to  affect  his  head;  a  poultice  was  ap- 
plied to  the  wound  on  the  calf  of  the  leg,  and 
strapping  on  that  at  the  ankle :  it  being  hoped,  that 
by  the  support  thus  afforded,  the  discharge  would 
be  diminished. 


DISLOCATIONS  OF  THE  TARSAL  BONES. 


357 


April  22.  As  his  appetite  does  not  improve,  and 
he  gets  no  sleep,  the  bark  and  opium  were  resumed, 
and  an  additional  pint  of  porter  given,  so  that  he  now 
takes  three  pints  a  day.  His  pulse  is  not  so  weak ; 
spirits  good;  at  times  he  is  in  great  pain  ;  strapping 
is  applied  to  all  the  wounds ;  the  sloughs  have  not 
separated. 

April  28.  Continues  much  the  same.  One  slough 
on  the  leg  has  separated,  that  at  the  ankle  not  yet  ; 
the  part  is  tolerably  easy  ;  the  discharge  not  great. 

May  15.  All  the  sloughs  have  separated,  and 
the  wounds  are  gradually  healing  up,  but  he  is  very 
weak,  and  his  appetite  is  bad. 

May  20.  Oil  was  ordered  to  be  rubbed  on  such 
parts  of  the  leg  as  would  bear  it,  and  then  washed 
off,  as  it  was  thought  this  would  promote  circulation 
in  the  limb,  which  was  cedematous  :  however,  this 
was  soon  discontinued,  as  it  occasioned  inflammation. 
About  this  time  his  medicines  were  omitted. 

May  29.  An  abscess,  which  had  formed  on  the 
calf  of  the  leg,  was  opened. 

July  14.  AH  the  dressings  were  left  off  to-day. 
He  is  perfectly  capable  of  lifting  his  leg,  and  has 
slight  flexion  and  extension  of  the  foot. 

After  this  time  he  rapidly  improved  :  and  having 
left  his  bed,  in  a  short  time  was  walking  about  the 
square  on  crutches. 

September  12.  He  went  out,  being  able  to  walk 
tolerably  well  with  a  stick. 


DISLOCATION  OF  THE  OS  CUNEIFORME  INTERNUM. 

I  have  twice  seen  this  bone  dislocated ;  once  in  a 
gentleman  who  called  upon  me  some  weeks  after 
the  accident,  and  a  second  time  in  a  case  which  oc- 


358  DISLOCATIONS   OF  THE  TARSAL  BONES. 


curred  in  Guy's  Hospital  very  lately.  In  both 
these  instances  the  same  appearances  presented 
themselves.  There  was  a  great  projection  of  the 
bone  inwards,  and  some  degree  of  elevation,  from 
its  being  drawn  up  by  the  action  of  the  tibialis 
anticus  muscle  ;  and  it  no  longer  remained  in  a  direct 
line  with  the  metatarsal  bone  of  the  great  toe.  In 
neither  case  was  the  bone  reduced.  The  subject 
of  the  first  of  these  accidents  walked  with  but  little 
halting,  and  I  believe  would  in  time  recover  the  use 
of  the  foot,  so  as  not  to  apf  ear  lame.  The  cause 
of  the  accident  was  a  fall  from  a  considerable 
height,  by  which  the  ligament  was  ruptured  which 
connects  this  bone  with  the  os  cuneiforme  medium, 
and  with  the  os  naviculare. 

The  second  case,  which  was  in  Guy's  Hospital, 
my  apprentice,  Mr  Babington,  informs  me, happened 
by  the  fall  of  a  horse,  through  which  the  foot  was 
caught  between  the  horse  and  the  curb-stone. 

The  treatment  of  this  injury  will  consist  in  con- 
fining the  bone  in  its  place,  by  at  first  binding  it  with 
a  roller  dipped  in  spirits  of  wine  and  water,  with 
Avhich  it  must  be  constantly  kept  wet :  and  when  the 
inflammation  is  subdued,  a  leather  strap  is  to  be 
buckled  around  the  foot,  to  keep  the  bone  in  its 
place  till  the  ligament  be  united. 

The  metatarsal  bones  I  have  never  known  luxated: 
their  union  with  each  other,  and  their  irregular  con- 
nexion with  the  tarsus,  prevent  it;  and  if  the  luxa- 
tion ever  happens,  it  must  be  a  very  rare  occur- 
rence. 


DISLOCATIONS   OF   THE   TARSAL  BONES. 


359 


DISLOCATION   OF  THE  TOES   FROM  THE  METATARSAL 
BONES. 

This  is  a  very  uncommon  accident:  but  I  had  a 
man  under  my  care  at  Guy's  Hospital,  who  had  such 
a  degree  of  lameness  as  to  be  unable  to  get  his 
bread  by  his  daily  labour,  owing  to  an  injury  sustain- 
ed by  falling  froni  a  considerable  height,  and  alight- 
ing upon  the  extremities  of  his  toes.  Upon  examina- 
tion of  the  bottom  of  the  foot,  a  considerable  pro- 
jection was  found  at  the  roots  of  all  the  smaller  toes, 
each  of  the  extremities  of  the  metatarsal  bones 
being  placed  under  the  first  phalanges  of  those  toes. 
Several  months  had  elapsed  from  the  time  of  the 
accident ;  and  at  first,  from  the  swelling  of  the  foot, 
it  had  not  been  detected.  No  extension,  at  the  time 
when  I  saw  him,  could  answer  any  purpose,  and  the 
only  mode  of  relief  was  to  wear  a  piece  of  hollow 
cork  at  the  bottom  of  the  inner  part  of  the  shoe,  to 
prevent  the  pressure  of  the  metatarsal  bones  upon 
the  nerves  and  blood-vessels. 

The  toes  are  sometimes  dislocated,  but  as  the 
mode  of  their  reduction  will  be  the  same  as  that  of 
the  fingers,  I  shall  reserve  the  subject  until  I  de- 
scribe the  dislocation  of  the  fingers. 


DISLOCATIONS  OP  THE   LOWER  JAW. 


Structure  of  the  articulation^  frc.  —  An  articular 
cavity  is  formed  behind  the  root  of  the  zygomatic 
process  of  the  temporal  bone,  which  receives  the 
condyloid  process  of  the  lower  jaw  at  the  time 
when  the  mouth  is  shut;  and  a  prominence  which 
is  placed  before  this  cavity  receives  the  lower  jaw 
when  the  teeth  are  advanced  upon  the  upper:  both 
the  cavity  and  the  prominence  are  covered  by  ar- 
ticular cartilage.  The  condyloid  process  of  the  jaw 
rests  in  the  cavity  with  an  intervening  cartilage 
whilst  the  mouth  is  shut,  but  it  advances  upon  the 
root  of  the  zygomatic  process  when  the  jaw  is  much 
opened,  or  the  lower  teeth  are  advanced.  Between 
the  condyloid  process  and  the  cartilaginous  surfaces, 
an  interarticular  cartilage  is  placed,  having  a  double 
concave  surface,  Avhich  allows  of  the  free  motion  of 
the  jaw,  and  of  its  advance  upon  the  zygomatic 
articular  tubercle;  whilst  the  coronoid  or  anterior 
process  of  the  jaw  is  received  between  the  zygo- 
matic arch  and  the  surface  of  the  temporal  bone. 

Ligaments.  —  A  capsular  ligament  unites  the  con- 
dyloid process  to  the  temporal  cavity  and  to  the 


DISLOCATIONS  OF  THE  LOWER  JAW.  351 


prominence  before  it,  and  joins,  in  its  passage  from 
one  bone  to  the  other,  the  edge  of  the  interarticu- 
lar  cartilage  ;  whilst  a  strong  internal  lateral  liga- 
ment passes  from  the  margin  of  the  articular  cavity 
to  the  inner  surface  of  the  angle  of  the  lower  jaw. 

Muscles.  —  The  jaw  is  drawri  upwards  and  down- 
wards, backwards  and  forwards,  and  transvei-sely. 
Its  elevation  is  produced  by  the  temporal,  the  mas- 
seter,  and  the  pterygoideus  internus:  its  depression 
by  the  platysma  myoidcs,  digastrlcus,  mylo  hyoideu?, 
genio  hyoldeus,  and  genio  hyo  glossus.  The  jaw  is 
drawn  backwards  by  tlie  temporal  muscle,  and  by  a 
part  of  the  masseter  :  and  when  the  os  hyoides  is 
fixed  by  the  digastrlcus,  the  gonlo  hyoldeus,  and 
genio  hyo  glossus,  it  is  pulled  forwards  by  a  portion 
of  the  masseter,  and  by  the  combined  action  of  the 
pterygoidel  externi. 

The  lateral  motions  of  the  jaw  are  principally 
produced  by  the  contractions  of  the  external  ptery- 
goid muscles,  which  in  alteriiate  actions  pull  the  jaw 
from  side  to  side,  and  give  it,  with  the  other  mus- 
cles, its  grinding  action,  in  which  these  muscles  are 
assisted  by  the  oblique  motion  forwards,  given  to 
the  jaw  by  the  pterygoideus  internus. 

Luxations.  —  The  lower  jaw  is  subject  to  two 
species  of  dislocation,  viz:  the  complete  and  the 
partial.  When  the  dislocation  is  complete,  both 
the  condyles  of  the  jaw  are  advanced  into  the  space 
between  the  zygomatic  arch  and  the  surface  of  the 
temporal  bone;  but  when  it  Is  partial,  one  condy- 
loid process  only  advances,  and  the  other  remains 
in  the  articular  cavity  of  the  temporal  bone. 

46 


362  DISLOCATIONS   OF  THE   LOWER  JAW. 

.,  -  i 

J 

K 

COMPLETE   LUXATION   OF  THE  JAW. 

Co7nplete  luxation;  symptoms.- — This  accident  is 
indicated  bj  the  open  state  of  the  mouthy  and  bj 
the  impossibility  of  closing  it,  either  by  the  patient's 
efforts,  or  by  pressure  made  upon  the  chin.  The 
lower  jaw  may  be  still  in  some  degree  approximated 
to  the  upper  by  muscular  efforts,  but  the  lower 
teeth,  if  the  mouth  could  be  closed,  would  be  in  a 
line  anterior  to  the  upper.  Some  degree  of  de- 
pression of  the  jaw  may  also  still  be  produced,  but  to 
an  inconsiderable  extent.  Thus  the  appearance  of  the 
patient  is  that  of  a  continued  yawning.  The  cheeks 
are  projected  by  the  advance  of  the  coronoid  pro- 
cesses towards  the  buccinator  muscle,  and  there  is  a 
depression  just  anterior  to  the  meatus  auditorius, 
from  the  absence  of  the  condyloid  process  from  its 
cavity.  The  saliva  is  not  retained  in  the  mouth,  but 
dribbles  over  the  chin;  and  a  very  considerable 
increase  of  this  secretion  follows,  in  consequence  of 
the  irritation  of  the  parotid  glands.  The  pain  ac- 
companying the  accident  is  severe,  but  I  have  never 
seen  any  dangerous  effect  produced  by  it:  on  the 
contrary,  the  jaw  becomes  more  nearly  closed  by 
time,  and  a  considerable  degree  of  motion  of  the 
jaw  is  recovered. 

Causes.  —  This  accident  may  be  caused  by  taking 
into  the  mouth  too  large  a  body  :  as  I  have  knoAvn 
when  two  boys  in  play,  struggling  for  an  apple,  one 
has  forced  it  into  his  mouth,  and  dislocated  his  jaw. 
A  blow  upon  the  chin,  when  the  mouth  is  widely 
opened,  produces  the  same  effect.  Yawning  very 
deeply  is  also  a  frequent  cause  of  the  accident. 

A  sudden  spasmodic  action  of  the  muscles  will 
produce  this  dislocation  when  the  mouth  is  opened  ; 


DISLOCATIONS   OF   THK   LOWER  JAW.  3tii5 

and  it  has  often  hap[)encd  in  attempts  to  extract  the 
teetli,  where  the  mouth  has  been  opened  too  widely. 
Mr  Fox,  dentist,  whose  death  we  have  to  deplore  as 
a  man  of  science,  informed  me  that  he  was  called 
to  a  lady  who  had  a  tooth  which  required  to  be  ex- 
tracted,  and  that  in  the  attempt  to  do  so,  a  sudden 
spasm  dislocated  the  jaw. 

In  this  accident,  the  jaw  must  be  immediately  re- 
stored to  its  situation;  and  the  mode  of  reduction  1 
shall  explain  by  the  following  case. 

Case  ;  reduction,  —  A  madman,  confined  in  one  of 
the  houses  in  Hoxton,  during  an  attempt  to  give  him 
some  food,  which  the  keeper  was  obliged  to  force 
him  to  receive,  had  his  jaw  dislocated.  Mr  Weston, 
surgeon  in  Shoreditch,  was  sent  for  ;  who,  finding  the 
man  very  powerful  and  very  unmanageable,  prefer- 
red rather  to  send  for  some  other  surgeon,  to  con- 
sider with  him  the  best  mode  of  making  the  attempt 
at  reduction.  When  I  saw  the  man  I  thought  that' 
^  surgeon  must  be  as  insane  as  the  patient  who 
would  employ  the  usual  means  of  reduction,  and  1 
therefore  desired  that  the  keepers  would  place  the 
patient  on  a  table  upon  his  back,  with  a  pillow  under 
his  head,  and  that  he  should  be  held  by  several 
persons.  1  ordered  two  table  forks  to  be  brought 
me,  and  wrapped  a  handkerchief  around  their  points. 
Placing#iyself  behind  the  patient's  head,  1  carried 
the  handles  of  the  forks  into  the  mouth,  on  each 
side,  behind  the  molares  teeth  ;  then  directed  them 
to  be  held,  and  placing  my  hand  under  the  chin,  I 
forcibly  drew  it  to  the  upper  jaw,  and  the  bone  w-as 
easily  and  quickly  reduced. 

Corks;  levers.  —  In  the  above  mentioned  case 
the  handles  of  the  forks  were  not  used  as  levers,  by 
lifting  them  ;  they  only  rested  upon  the  jaw,  which 
was  used  as  a  lever  upon  them,  depressing  the  pro- 
cesses as  the  jaw  was  elevated,  and  thus  directing 


364  DISLOCATIONS   OF  THE  LOWER  JAW. 


the  bone  backwards  into  its  natural  situation.  But 
as  wood  is  liable  to  injure  the  gums,  it  is  better  to 
substitute  two  corks,  which  are  to  be  placed  behind 
the  molares  teeth  on  each  side  of  the  mouth,  and 
over  these  the  chin  is  to  be  raised.  Thej  are 
eqijal!j  effectual  in  reducing  the  bone,  and  are  less 
hkely  to  injure  it,  or  to  bruise  the  soft  parts.  It 
has  been  recommended  in  these  cases,  to  use  a 
piece  of  wood  as  a  lever,  by  introducing  it  between 
the  molares  teeth,  first  on  one  side  and  then  on  the 
other,  reducing  one  side  first,  and  then  using  the 
same  means  to  the  other.  Mr  Fox,  in  the  case 
before  alluded  to,  thus  succeeded  :  he  placed  a 
piece  of  wood,  a  iboi  long,  upon  the  molar  tooth  on 
one  side,  and  raising  it  at  the  part  at  which  he  iield 
it,  depressed  the  point  at  the  jaw  on  that  side,  and 
reduced  the  jaw.  He  then  performed  the  same 
operation  on  the  other  side,  and  thus  replaced  the 
bone.  But  the  corks,  the  recumbent  posture,  and 
the  elevation  of  the  chin,  constitute  the  mode  which 
I  prefer. 

Dislocation  liable  to  occur.  —  In  reducing  this  dis- 
location, the  surgeon  generally  wraps  a  handker- 
chief round  his  thumbs,  placing  them  at  the  roots 
of  the  cororioid  j)rocesses,  and  depressing  the  jaw, 
forces  it  backwards  as  well  as  downwards,  when  the 
bone  suddenly  shps  into  its  place:  but  t^'s  mode 
does  not  so  easily  succeed  as  the  others,  excepting 
in  recent  dislocations.  When  the  jaw  has  been  once 
dislocated,  it  is  very  liable  to  the  same  accident,  and 
therefore  a  broad  tape,  with  a  hole  cut  in  it  to  re- 
ceive the  chin,  divided  into  four  ends  by  splitting  it 
on  each  side  some  way  down,  is  to  be  tied  over  the 
summit  of  tlie  head  and  occiput,  to  confine  the  jaw 
until  the  lacerated  parts  have  healed,  by  which  the 
tendency  to  subsequent  luxation  is  diminished. 


DISLOCATIONS   OF  THE  LOWER  JAW. 


365 


PARTIAL  DISLOCATION   OF  THE  JAW. 

Partial  dislocation;  symptoms.  —  In  this  case,  the 
condjlold  process  advances  under  the  zygomatic  arch 
on  one  side  only,  producing  an  Incapacity  to  close 
the  mouth;  but  it  is  not  so  widely  opened  as  in  the 
complete  dislocation.  It  is  easy  to  distinguish  tills 
accident,  as  the  chin  is  thrown  to  the  side  oj)posite 
to  the  luxation,  and  the  incisores  teeth  are  iiot  only 
advanced  upon  the  upper  jaw,  but  are  no  longer  in 
a  line  with  the  axis  of  the  face.  The  cause  of  this 
accident  is  a  blow  on  the  side  of  the  face  when 
the  mouth  is  opened,  and  in  one  case  it  occurred 
from  vomiting  in  sea  sickness.  In  this  example,  the 
lady,  Miss  Belfour,  daughter  of  the  late  Admiral 
Belfour,  of  Portsmouth,  reduced  her  jaw  by  an  oys- 
ter-knife, which  she  turned  half  round  upon  ine 
side  of  the  jaw  between  the  teeth,  and  so  returned 
it  to  its  place. 

In  this  injury,  the  lever  of  wood  reduces  the  bone 
most  easily,  but  the  cork  may  be  used  on  one  side, 
and  the  chin  be  elevated,  as  in  those  cases  in  which 
the  dislocation  is  complete. 


SUBLUXATION  OF    THE  JAW. 

Symptoms,  Src  —  As  in  the  knee,  the  thigh-bone 
is  sometimes  thrown  from  its  semllunur  cartilages, 
so  the  jaw  appears  occasionally  to  quit  the  inter- 
articular  cartilage  of  the  temporal  cavity,  slipping 
before  its  edge,  and  locking  the  jaw,  with  the  mouth 
slightly  opened.  It  generally  happens,  that  this  dis- 
location is  quickly  removed  by  natural  efforts  alone; 
but  I  have  seen  it  continue  for  a  length  of  time,  and 


366  DISLOCATIONS   OF   THE  LOWER  JAW. 

the  motion  of  the  jaw,  and  the  power  of  closing  the 
mouth  have  still  returned.  This  state  of  the  jaw 
happens  from  extreme  relaxation.  The  patient  finds 
himself  suddenly  incapable  of  entirely  closing  the 
mouth  ;  some  pain  is  felt,  and  the  mouth  is  least 
closed  on  that  side  on  which  the  pain  is  felt. 

Reduction. —  Force  for  removing  these  appearances 
must  be  applied  directly  downw^ards,  so  as  to  sepa- 
rate the  jaw^  from  the  temporal  bone,  and  to  give  an 
opportunity  for  the  cartilage  to  replace  itself  upon 
the  rounded  extremity  of  the  condyloid  process. 

Relaxation  of  ligaments.  —  In  extreme  degrees  of 
relaxation,  a  snapping  is  felt  in  the  maxillary  articu- 
lation just  before  the  ear,  with  some  pain,  arising 
from  the  sudden  relapse  of  the  jaw  into  its  socket, 
which  the  relaxation  of  the  ligament  had  permitted 
it^to  quit,  and  to  advance  upon  the  zygomatic  tu- 
bercle. 

Young  women  are  generally  subject  to  this  sensa- 
tion, and  the  means  which  I  have  found  most  fre- 
quently and  quickly  tending  to  insure  their  recovery 
have  been  ammonia  and  steel  as  medicine;  with  the 
shower-bath,  and  the  application  of  a  blister  before 
the  ear,  when  the  complaint  has  continued  for  a 
length  of  time. 


DISLOCATIONS    OF    THE  CLAVICLE. 


Dislocations  rare.  —  As  the  clavicle  is  the  only 
medium  by  which  the  arm  is  articulated  with  the 
bones  of  the  chest,  it  might  be  expected  that  its 
dislocation  would  be  extremely  frequent  ;  but  this 
bone  is  so  peculiarly  and  strongly  articulated,  both 
with  the  sternum  and  scapula,  as  to  render  its  dislo- 
cation comparatively  rare. 

jirticulation,  —  In  other  articulations  we  find  a  cap- 
sular ligament  proceeding  from  the  edges  of  the  ar- 
ticulating surfaces  and  peculiar  ligaments,  to  give 
strength  to  the  junction  of  the  bones  ;  but  in  the 
articulation  of  the  clavicle,  like  that  of  the  lower 
jaw  and  knee,  we  meet  with  an  interarticular  car- 
tilage, composing  a  part  of  the  articulating  appa- 
ratus. 


JUNCTION   OP  THE  STERNAL  EXTREMriY  OF  THE  CL'AVICLE 
WITH   THE  STERNUM. 

Bones.  —  The  articulating  surfaces,  both  of  the 
sternum  and  clavicle,  are  in  part  rounded,  and  in 


368  DISLOCATIONS  OF  THE  CLAVICLE. 


part  depressed ;  and  both  are  covered  by  an  articu- 
lar cartilage  similar  to  that  of  the  other  joints.  A 
capsular  ligament  proceeds  from  the  end  of  tlie  cla- 
vicle to  the  edge  of  the  articulating  surfaces  of  the 
sternum,  and  it  is  strengthened  by  short  ligaments, 
which  pass  directly  from  one  bone  to  the  other.  . 

Inter  articular  cartilage^  8{c,  —  Within  the  capsular 
ligament  is  situated  the  interarticular  cartilage,  joined 
at  the  upper  part  of  the  joint  to  the  clavicle,  and  to 
the  caj)sular  ligament  ;  and,  below,  to  the  edge  of 
the  articular  surface  of  the  sternum,  and  to  the  cap- 
sular ligament;  it  is  inclined  under  the  end  of  the 
clavicle  with  ihe  capsular  ligament,  so  that  the 
clavicle  rests  upon  its  surface,  and  it  is  also  interpos- 
ed between  that  bone  and  the  sternum.  Of  that 
portion  of  this  cartilage  which  is  inclined  to  the 
clavicle,  only  about  on.e  half  is  smooth,  to  allow  of 
the  motion  of  that  bone,  and  this  is  its  lower  and 
anterior  part.  The  residue  of  it  adheres  to  the 
articular  cartilage  of  the  clavicle,  forming  a  flat, 
rouo^h  surface;  but  on  the  side  towards  the  sternum 
the  interarticular  cartilage  forms  a  smooth  and  con- 
cave surface,  which  allows  of  its  free  motion  on  that 
bone.  The  interarticular  cartilage  is  placed  not 
perpendicularly,  but  obliquely  ;  its  upper  end  is  in- 
clined inwards,  and  its  lower  end  outwards,  towards 
the  first  rib.  From  the  upper  point  of  the  clavicle 
proceeds  an  interclavicular  ligament,  which  adheres 
to  the  capsular  ligament,  and  slightly  to  the  sternum; 
and  traversing  the  upper  and  back  part  of  the 
sternum,  it  is  fixed  in  the  extremity  of  the  opposite 
clavicle,  and  unites  very  strongly  one  clavicle  to  the 
other. 

Clavicular  costal  ligament.  —  The  clavicle  is  also 
joined  to  the  first  rib  by  a  clavicular  costal,  or,  as  it 
is  called,  rhomboid  ligament,  which  proceeds  from  the 
inferior  edge  of  the  sternal  en^  of  the  clavicle  to 
the  cartilage  of  the  first  rib. 


DISLOCATIONS  OF  THE  CLAVICLE. 


369 


Motion  of  the  clavicle,  — The  motion  of  the  clavi- 
cle, as  well  as  that  of  the  sternum,  forwards  and 
backwards,  is  performed  upon  the  smooth  surface  of 
the  interarticular  cartilage,  which  is  applied  to  the 
sternum;  whilst  the  motion  of  the  clavicle,  upwards 
and  downwards,  is  produced  upon  the  portion  of  the 
smooth  surface  of  the  interarticular  cartilage,  which 
is  applied  to  the  clavicle;  and  another  advantage 
derived  from  this  mode  of  articulation  is,  that  it  al- 
lows of  the  motion  of  the  bone  outwards  and  back- 
wards to  a  considerable  extent,  without  occasioning 
any  weakness  in  the  ligament :  for,  in  this  view,  it 
may  be  considered  that  there  are  two  ligaments; 
one  from  the  clavicle  to  the  cartilage,  and  one  from 
the  cartilage  to  the  sternum,  instead  of  one  loose, 
long  ligament  from  bone  to  bone. 


DISLOCATION  OF  THE   STERNAL  EXTREMITY   OF  THE 
CLAVICLE. 

These  are  of  two  kinds,  viz  :  —  the  dislocation 
forwards,  the  clavicle  being  then  thrown  upon  the 
Sternum ;  or  backwards^  when  the  end  of  the  bone 
is  placed  behind  the  sternum. 

Dislocation  Forwards. 
The  circumstances  by  which  this  injury  is  known 
are,  that  upon  looking  at  the  upper  part  of  the 
sternum,  a  rounded  projection  is  seen;  and  when 
the  fingers  are  carried  upon  the  surface  of  the 
sternum  upwards,  this  projection  stops  them.  If 
the  surgeon  places  himself  behind  the  patient,  puts 
his  knees  between  the  scapulae,  grasps  the  shoulders 
and  draws  them  back,  the  projection  on  the  sternum 

47 


370  DISLOCATIONS  OP  THE  CLAVICLfi. 


disappears;  but  directly  when  the  shoulders  advance, 
the  projection  upon  the  sternum  is  renewed.  The 
clavicle  may  be  readily  (raced  with  the  finger  into 
the  projection  on  the  sternum.  If  the  shoulder  be 
elevated,  the  projection  descends;  if  it  be  drawn 
downwards,  the  dislocated  extremity  of  the  bone 
becomes  elevated  to  the  neck.  The  motions  of  the 
dislocated  clavicle  are  painful,  and  the  patient  moves 
the  shoulder  with  difficulty.  The  point  of  the  in- 
jured shoulder  is  less  distant  from  the  central  line  of 
the  sternum  than  usual.  In  a  very  thin  person  the 
nature  of  the  accident  can  be  at  once  ascertained, 
because  the  bone  is  but  little  covered  ;  but  in  fat 
persons  it  is  more  difficult  to  detect.  When  the 
patient  is  at  rest,  very  little  pain  or  tenderness  is  felt 
from  the  accident.  It  sometimes  happens  that  this 
dislocation  is  incomplete,  the  anterior  portion  of  the 
capsular  ligament  only  being  torn,  and  the  bone 
slightly  projecting;  but  generally  all  the  ligaments 
are  lacerated,  and  the  bone,  with  its  interarticular 
cartilage,  is  thrown  forwards. 

Its  cause.  —  The  cause  of  this  injury  is  a  fall  up- 
on the  point  of  the  shoulder,  when  the  force  pushes 
the  clavicle  inwards  and  forwards,  and  projects  it  on 
the  sternum:  but  it  also  frequently  happens  from  a 
fall  upon  the  elbow  at  the  time  when  it  is  separated 
from  the  side,  by  which  the  clavicle  is  forced  violent- 
ly inwards  and  forwards  against  the  anterior  part  of 
the  capsular  ligament. 

Reduction.  —  With  respect  to  the  means  of  re- 
duction and  the  principle  upon  which  the  treatment 
is  to  be  regulated,  there  is  no  difficulty  in  practising 
the  one,  or  in  understanding  the  other.  The  clavicle 
is  easily  returned  to  its  place  by  pulling  the  shoulder 
backwards,  because  then  it  is  drawn  off  the  sternum, 
and  its  end  falls  upon  the  cavity  which  naturally  re- 
ceived it ;  but  if  pressure  in  this  position  of  the 


DISLOCATIONS  OF  THE  CLAVICLE. 


shoulder  be  not  made  upon  the  fore  part  of  the 
bone,  it  will  be  found  still  liable  to  project  in  some 
degree. 

Principle, —  The  principle,  therefore,  upon  which 
the  extension  is  made,  is  to  draw  the  scapula  as  far 
from  the  side  as  is  practicable  without  inconvenience, 
and  by  supporting  the  arm,  to  prevent  its  weight 
from  influencing  the  position  of  the  bone. 

Mode  of  extension,  —  The  first  of  these  objects  is 
best  effected  by  the  use  of  the  clavicle  bandage  [see 
Plate),  and  by  the  application  of  two  pads  or  cush- 
ions affixed  to  it,  which  are  placed  in  the  axillae. 
These  pads  throw  the  head  of  the  os  humeri  from 
the  side,  and  carry  the  scapula,  and  the  clavicle  con- 
nected with  it,  outwards  and  backwards,  and  thus 
the  clavicle  is  drawn  into  its  natural  articular  cavity. 
The  second  intention  is  effected  by  putting  the  arm 
in  a  sling,  which,  through  the  medium  of  the  os  hume- 
ri and  scapula,  supports  it,  and  prevents  the  clavicle 
from  being  drawn  down  by  the  weight  of  the  arm. 

Dislocation  Backwards, 

Dislocation  backwards,  —  The  dislocation  of  the 
extremity  of  the  bone  backwards  I  have  never 
known  to  occur  from  violence,  yet  it  might  happen 
from  excessive  force,  as  from  a  blow  upon  the  fore 
part  of  the  bone,  which  should  tear  the  capsular  and 
clavicular  costal  ligament,  and  allow  the  bone  to  glide 
behind  the  sternum,  occasioning  compression  of  the 
oesophagus,  and  rendering  deglutition  difficult.  The 
trachea  would,  from  its  elasticity,  elude  pressure  and 
escape  to  the  opposite  side  of  the  space  by  which 
this  tube  enters  the  thorax. 

Cause.  —  The  only  cause  of  this  dislocation  that 
I  have  known,  was  produced  by  great  deformity  of 
the  spine,  by  which  the  scapula  advanced,  and  suffi- 
cient space  was  not  left  for  the  clavicle  between  the 


372  DISLOCATIONS   OP  THE  CLAVICLE. 


scapula  and  sternum  ;  in  consequence  of  which,  the 
bone  gradually  glided  back  behind  the  sternum,  and 
produced  so  much  inconvenience  by  its  pressure  on 
the  oesophagus,  as  to  lead  to  a  necessity  for  the  re- 
moval of  its  sternal  extremity. 

This  case  is  extremely  creditable  to  the  know- 
ledge, skill,  and  dexterity  of  Mr  Davie,  surgeon  at 
Bungay,  in  Suifolk  ;  few  would  have  thought  of  the 
mode  of  relief — very  few  would  have  dared  to 
perform  the  operation  —  and  a  still  smaller  number 
v/ould  have  had  sufficient  knowledge  for  its  accom- 
plishment. 

The  following  particulars  I  in  part  received  in 
conversation  with  Mr  Davie,  who  fell  a  victim  to 
his  great  professional  zeal,  and  in  part  from  Mr 
Henchman  Crowfoot,  surgeon  at  Beccles.  He  had 
the  kindness  to  go  over  to  Dr  Camell,  of  Bungay,  to 
learn  from  him  some  of  the  particulars,  and  there 
met  with  a  person  who  gave  him  several  others,  and 
who  knew  the  patient  for  some  years  after  the 
operation. 

Case.  —  Miss  Loffly,  of  Metfield,  Suffolk,  had  a 
great  deformity,  arising  from  a  distorted  spine,  in- 
creased by  an  accident  which  displaced  the  sternal 
extremity  of  the  left  clavicle,  and  threw  it  behind 
the  sternum.  The  progressive  distortion  of  the  spine 
gradually  advanced  the  scapula,  and  occasioned  the 
sternal  end  of  the  clavicle  to  project  inwards,  behind 
the  sternum,  so  as  to  press  upon  the  oesophagus,  and 
occasion  extreme  difficulty  in  deglutition.  Her  de- 
formity had  become  excessive,  and  her  emaciation 
extreme. 

Mr  Davie  conceived  that  he  should  be  able  to 
prevent  the  gradual  destruction  which  the  altered 
position  of  the  clavicle  threatened,  by  removing  the 
sternal  extremity  of  the  bone  ;  and  the  operation 


DISLOCATIONS  OF  THE  CLAVICLE.  373 


which  he  performed  for  this  purpose  was,  according 
to  all  I  can  learn,  as  follows. 

An  incision  was  made  of  from  two  to  three  inches 
in  extent  on  the  sternal  extremity  of  the  clavicle,  in 
a  line  with  the  axis  of  that  bone  ;  and  its  surround- 
ing ligamentous  connexions,  as  far  as  he  could  then 
reach  them,  were  divided  with  the  saw  of  Scultetus 
(often  called  Hey's) ;  he  sawed  through  the  end  of 
the  bone,  one  inch  from  its  articular  surface  from 
the  sternum,  and  fearful  of  doing  unnecessary  injury 
with  the  saw,  he  introduced  a  piece  of  well-beaten 
sole  leather  under  the  bone  whilst  he  divided  it. 
When  the  sawing  was  completed  he  tried  to  detach 
the  bone,  but  it  still  remained  connected  by  its  inter- 
clavicular ligament,  and  he  was  obliged  to  tear 
through  that  ligament  by  using  the  handle  of  the 
knife  as  an  elevator,  and  after  some  time  succeeded 
in  removing  the  portion  of  bone  which  he  had  sepa- 
rated. 

The  wound  healed  without  any  untoward  occur- 
rence, and  the  patient  was  enabled  to  swallow,  as 
the  pressure  of  the  clavicle  upon  the  oesophagus 
was  now  removed. 

She  lived  six  years  after  the  operation,  and  re- 
covered considerably  from  her  former  emaciation. 
'  Of  what  she  ultimately  died,'  says  Mr  Crowfoot, 
'  I  have  not  learnt.' 


JUNCTION  OP  THE  CLAVICLE  WITH  THE  SCAPULA. 

Articulation  ;  ligaments,  S^c.  —  The  clavicle  joins 
with  the  scapula  about  three  quarters  of  an  inch  be- 
hind the  extremity  of  the  acromion.  The  end  of 
the  clavicle  is  slightly  convex,  and  covered  by  an  ar- 
ticular cartilage  ;  the  scapula  is  depressed  to  receive 


374 


DISLOCATIONS  OP    THE  CLAVIOLE. 


it,  and  this  surface  is  also  covered  by  an  articular 
cartilage.  Strong  ligamentous  fibres  pass  directly 
from  the  clavicle  to  the  scapula,  and  under  these  a 
capsular  ligament  is  extended  from  the  edge  of  the 
socket  of  the  scapula,  to  the  extremity  of  the  clavi- 
cle. The  surface  of  junction  is  very  small,  the  end 
of  the  clavicle  not  being  longer  than  the  end  of  the 
little  finger  of  an  adult ;  and  the  cavity  in  the  scap- 
ula which  receives  it  is  very  superficial,  being  not 
larger  than  is  required  to  receive  upon  its  surface  the 
end  of  the  clavicle.  But  the  junction  of  the  two 
bones  is  effected  by  much  stronger  means,  through 
the  medium  of  the  coracoid  process  of  the  scapula, 
which  sends  forth  two  ligaments  to  the  clavicle.  The 
first  proceeds  from  the  root  of  the  coracoid  process, 
and  is  fixed  in  a  small  tubercle  of  the  clavicle  on  its 
under  side,  at  the  insertion  of  the  subclavius  muscle, 
and  two  inches  from  the  extremity  of  the  bone* 
This  ligament  has  been  called  the  conoid,  from  its 
form,  but  may  be  better  named  the  internal  coraco- 
clavicular.  The  use  of  this  ligament  is,  to  bind 
down  the  clavicle  to  the  scapula,  and  to  confine  the 
motion  of  the  clavicle  forwards  and  upwards. 

External  coraco-clavicular.  —  The  second  ligament 
of  this  part  is  called  trapezoid  ;  it  proceeds  from  the 
coracoid  process,  and  passes  on  the  under  side  of  the 
clavicle  to  near  its  scapular  end,  into  which  it  is  fix- 
ed; I  call  it  the  external  coraco-clavicular.  This  lig- 
ament is  the  chief  cause  which  lessens  the  tendency 
to  dislocation  of  the  scapular  end  of  the  clavicle,  for 
when  its  capsular  ligament  is  divided,  the  scapula 
cannot  be  forced  under  the  clavicle  without  lacerating 
this  ligament,  so  great  is  its  resistance.  It  allows  of 
very  free  motion  of  the  scapula  backwards  and  up- 
wards, but  confines  its  motions  forwards.  The  mo- 
tions of  this  extremity  of  the  clavicle  are  perfomed 
by  the  subclavius  muscle,  although  other  muscles  also 
move  this  bone. 


DISLOCATIONS  OP  THE  CLAVlCLlEi.  375 


DISLOCATION    OF    THE    SCAPULAR    EXTREMITY    OP  THE 

CLAVICLE. 

This  accident  is  more  frequent  than  the  dislocation 
of  the  sternal  extremity. 

When  this  extremity  of  the  bone  is  luxated,  the 
signs  by  which  the  surgeon  ascertains  the  nature  of 
the  injury  are  as  follow. 

Symptoms.  —  The  shoulder  on  that  side,  when 
compared  with  the  opposite,  appears  depressed,  for 
the  clavicle  is  formed  to  give  support  to  the  scapu- 
la, and  that  support  is  lost  in  consequence  of  the  ac- 
cident. The  point  of  the  shoulder  approaches  near- 
er to  the  sternum  ;  and  if  the  distance  of  the  two 
shoulders  from  that  bone  be  measured,  this  inequali- 
ty is  directly  detected;  the  clavicle  being  naturally 
the  means  of  preserving  the  distance  of  the  scapula 
from  the  side,  to  throw  out  the  shoulders,  and  to  ren- 
der the  motions  of  the  arm  extensive.  But  the 
easiest  mode  of  detecting  this  accident  is,  to  place  the 
finger  upon  the  spine  of  the  scapula,  and  to  trace 
this  portion  of  bone  forward  to  the  acromion  in  which 
it  ends;  the  finger  is  stopped  by  the  projection  of 
the  clavicle,  and  so  soon  as  the  shoulders  are  drawn 
back,  the  point  of  the  clavicle  sinks  into  its  place, 
but  it  re-appears  when  the  shoulders  are  let  go. 
The  point  of  the  clavicle  projects  against  the  skin 
upon  the  superior  part  of  the  shoulder,  and  much 
pain  is  felt  when  it  is  pressed. 

In  this  injury,  the  capsular  ligament  is  necessarily 
torn  through,  as  well  as  the  external  ligament,  from 
the  coracoid  process  to  the  clavicle,  or  no  dislocation 
of  the  sternal  extremity  could  occur.  The  internal 
ligament,  when  the  dislocation  is  complete,  must  be 
also  lacerated ;  but  I  have  seen  the  clavicle  project 
but  slightly  on  the  acromion  in  some  of  these  acci- 


376 


DISLOCATIONS  OF  THE  OLAVICLE. 


dents,  denoting  that  the  latter  ligament  had  not 
given  way. 

It  is  scarcely  probable,  that  the  clavicle  should  be 
ever  dislocated  in  any  other  direction  than  upwards. 
At  least  I  have  never  seen  an  instance  of  the  clavi- 
cle gliding  under  the  acromion,  but  I  would  not  deny 
the  possibih'ty  of  such  an  accident. 

Cause,  —  This  species  of  dislocation  is  caused  by 
a  fall  upon  the  shoulders,  through  which  the  scapula 
is  forced  inward  towards  the  ribs,  and  the  accident 
which  produces  it  is  excessively  violent.  It  has  been 
said,  that  the  action  of  the  trapezius  muscle  alone 
could  produce  this  effect,  but  that  is  impossible,  as 
this  muscle  would  not  influence  both  the  ligaments 
of  the  coracoid  process,  which  must  be  torn  through 
to  produce  the  dislocation. 

Reduction,  —  In  the  treatment  of  this  accident,  I 
adopt  the  following  plan  :  The  assistant,  standing 
behind  the  patient,  puts  his  knee  between  the  shoul- 
ders, and  draws  them  backwards  and  upwards,  when 
the  clavicle  sinks  into  its  socket.  A  thick  cushion  is 
then  placed  in  each  axilla,  for  three  purposes  :  First, 
to  keep  the  scapula  from  the  side  :  Secondly,  to 
raise  the  scapula:  Thirdly,  to  defend  the  axillae 
from  being  hurt  by  the  bandages:  on  which  last  ac- 
count a  cushion  is  employed  on  each  side.  Then 
the  clavicle  bandage  is  applied,  and  its  straps  should 
be  sufficiently  broad  to  press  upon  the  clavicle,  the 
scapula,  and  the  upper  part  of  the  os  humeri,  to  keep 
the  former  down,  the  scapula  inwards  and  backwards 
(which  is  the  chief  object),  and  the  arm  backwards 
and  elevated.  To  secure  these  objects  more  effec- 
tually, the  arm  is  to  be  suspended  in  a  short  sling,  by 
which  it  is  made  to  support  the  scapula  in  its  proper 
situation. 

At  the  conclusion  of  my  lecture  upon  this  subject 
I  have  always  given  this  counsel  to  the  pupils:  — 


DISLOCATIONS  OF  THE  CLAVICLE. 


377 


'You  are  not  to  expect  that  the  parts,  after  the  ut- 
most care  in  the  treatment,  will,  in  dislocations  of 
either  end  of  the  clavicle,  be  very  exactly  adjusted; 
some  projection,  some  slight  deformity  will  remain  ; 
and  it  is  necessary,  from  the  first  moment  of  the 
treatment,  that  this  should  be  stated  to  the  patient, 
as  he  may  otherwise  suspect  that  the  fault  has  arisen 
from  your  ignorance  or  negligence.  You  may  at  the 
same  time  inform  him,  that  a  very  good  use  of  the 
iimb  will  be  recovered,  although  some  deviation  from 
the  natural  form  of  the  parts  may  remain,  in  a  slight 
projection  on  the  sternum,  or  some  elevation  of  the 
sternal  extremity  of  the  clavicle.' 


DISLOCATION  OF  THE  CLAVICLE  WITH  FRACTURE  OF  THE 
ACROMION. 

We  have  a  preparation  of  this  injury  in  the  Mu- 
seum at  St  Thomas's  Hospital,  and  the  following  ac- 
count of  the  case  was  given  me  by  Mr  South. 

Case.  —  A  man,  aged  sixty  years,  was  admitted 
into  King's  Ward,  St  Thomas's  Hospital,  October 
19,  1814,  having  fallen  from  a  tree  two  or  three  days 
before.  The  surgeon  to  whom  he  applied  told  him 
that  nothing  was  injured  ;  but  he  himself  persisted 
in  saying  his  shoulder  was  broken,  and  walked  up 
from  Maidstone  to  the  hospital.  On  examination, 
his  shoulder  appeared  fallen  as  if  displaced,  but  a 
little  attention  showed  that  this  was  not  the  case. 
What,  however,  the  accident  was  determined  to  be, 
I  do  not  recollect ;  but  the  following  treatment  was 
adopted.  Cushions  were  put  in  the  axilla9,  and  a 
stellate  bandage  applied,  with  another  just  above  the 
elbow  to  bind  it  to  the  side,  and  the  arm  was  put  in 
a  sling,  which  seemed  to  keep  the  parts  in  their  pro- 

48 


378 


DISLOCATIONS   OF   THE  CLAVICLE. 


per  position;  but  the  next  morning  the  bandages  were 
loose.  Supposing  that  this  effect  was  produced  by 
restlessness,  they  were  again  applied,  but  continued 
slipping  off,  day  after  day,  until  a  week  from  his  ad- 
mission, when  a  long  splint,  placed  across  the  shoul- 
ders, was  bound  to  them  by  rollers,  and  the  parts  re- 
sumed their  natural  situation ;  but  after  a  short  time, 
they  were  also  obliged  to  be  removed  on  account  of 
the  extreme  irritability  of  the  patient.  He  was 
then  ordered  to  lie  in  bed  upon  his  back  without  any 
bandage,  but  the  parts  became  again  displaced.  No 
other  attempt  at  relief  was  made,  and  he  died  on 
December  the  7th  following,  of  some  pulmonary 
disease,  after  an  illness  of  three  weeks. 

Clavicle  dislocated;  acromion  broken,  —  On  exami- 
nation of  his  body,  the  clavicle  was  found  dislocated 
at  its  scapular  extremity,  and  projected  considerably 
over  the  spine  of  thai  bone.  The  acromion  pro- 
cess, just  where  the  clavicle  is  united  with  it,  was 
broken  off. 

The  splint  across  the  shoulders  seemed  likely  to 
have  succeeded  in  keeping  the  parts  in  apposition,  if 
the  man's  illness  and  impatience  would  have  permit- 
ted him  to  continue  to  wear  it. 


STRUCTURE  OF  THK  SHOULDER-JOINT. 


Shoulder-joint  —  The  shoulder-joint  is  composed 
of  two  portions  of  bone ;  the  glenoid  cavity  of  the 
scapula,  and  the  head  of  the  os  humeri. 

Glenoid  cavity.  —  The  glenoid  cavity  is  similar  in 
form  to  a  longitudinal  section  of  an  egg,  with  its  lar- 
ger extremity  downwards  and  outwards,  and  its  small- 
er upwards  and  inwards;  the  cavity  is  so  superficial, 
that  the  head  of  the  humerus  rather  rests  upon  its 
surface  than  is  received  into  its  hollow ;  it  is,  how- 
ever, slightly  concave,  and  is  covered  by  an  articular 
cartilage,  which  is  somewhat  extended  beyond  the 
edge  of  the  bony  cavity. 

Coracoid  process.  —  The  coracoid  process  of  the 
scapula  is  situated  at  the  upper  point  of  the  glenoid 
cavity,  and  its  basis  extends  from  thence  to  the  notch 
of  the  superior  costa ;  it  rises  and  inclines  inwards 
and  forwards,  terminating  in  a  point,  which  is  situat- 
ed under  the  clavicle,  one  third  the  length  of  that 
bone  from  its  junction  with  the  spine  of  the  scapula, 
and  on  the  inner  side  of  the  head  of  the  os  humeri, 
under  the  pectoral  muscle.  It  covers  and  protects 
the  joint  on  its  inner  side. 


380 


STRUCTURE  OF  THE  SHOULDER-JOINT. 


Cervix  scapulce,  —  The  glenoid  cavity  is  united  to 
the  body  of  the  scapula  by  a  narrow  neck,  which  is 
called  the  cervix  scapulas;  and  its  narrowest  part  is 
opposite  to  the  notch  of  the  superior  costa  of  the 
scapula. 

Head  of  the  humerus.  — The  head  of  the  humerus 
is  divided  into  three  portions.  The  first  is  an  articu- 
lar surface  forming  a  small  part  of  a  sphere,  which 
rests  upon  the  glenoid  cavity  of  the  scapula,  and  is 
covered  with  an  articular  cartilage  ;  the  second  is  a 
process  called  the  larger  tubercle,  formed  for  the 
insertion  of  three  muscles  ;  it  is  situated  on  the  outer 
portion  of  the  head  of  the  bone,  under  the  deltoid 
muscle  ;  and  the  third  is  a  process  called  the  lesser 
tubercle,  which  is  situated  on  the  inner  side  of  the 
head  of  the  bone  towards  the  axilla;  and  in  the  usu- 
al position  of  the  arm,  nearly  in  a  line  with  the  point 
of  the  coracoid  process  of  the  scapula. 

Bicipital  groove,  —  Between  these  two  processes 
is  a  groove,  which  lodges  the  tendon  of  the  long  head 
of  the  biceps  muscle,  and  is  termed  the  bicipital 
groove. 

Cervix  humeri.  —  Immediately  below  the  head  of 
the  humerus  is  situated  that  portion  of  the  bonjB 
called  the  cervix  humeri. 

Capsular  ligament.  —  The  capsular  ligament  of 
this  joint  surrounds  the  head  of  the  bone,  and  is  at- 
tached to  the  whole  circumference  of  the  edge  of 
the  glenoid  cavity,  excepting  where  the  tendon  of 
the  biceps  muscle  passes  under  it;  and  at  that  point 
it  arises  I'rom  a  ligament  which  proceeds  from  the  co- 
racoid process  to  the  edge  of  the  glenoid  cavity. 
The  capsular  ligament  is  also  fixed  to  the  two  tuber- 
cles, and  towards  the  axilla,  to  the  neck  of  the  hume- 
rus, just  below  its  articular  surface.  This  ligament 
is  not  of  a  uniform  thickness ;  but  at  those  parts 
where  the  joint  is  not  defended  from  injury  by  the 
tendinous  insertions  of  muscles,  the  capsular  ligament 


STRUCTURE  OF  THE  SHOULDER-JOINT. 


381 


itself  is  thickened,  and  is  capable  of  sustaining  great 
violence  ;  and  this  difference  is  remarkably  shown  in 
that  part  of  the  ligament  which  is  placed  in  the  ax- 
illa, it  being  of  a  strong  tendinous  nature. 

Muscles  of  protection  to  the  joint.  —  Four  muscles 
are  destined  to  move  the  os  humeri,  and  to  strength- 
en the  capsular  ligament.    The  first,  the  supra-spi- 
natus,  which  arises  from  the  fossa  supra-spinata, 
covers  the  head  of  the  bone^  blends  its  tendon  with 
the  capsular  ligament,  and  is  inserted  into  the  larger 
tubercle;   the   second,  the  infra-spinatus  muscle, 
which  proceeds  from  the  fossa  infra-spinata,  adheres 
to  the  back  part  of  the  capsular  ligament,  and  is  also 
fixed  to  the  greater  tubercle ;  the  third,  the  teres 
minor,  which  arises  from  the  lower  edge  of  the  sca- 
pula, adheres  to  the  back  part  of  the  capsular  liga- 
ment, and  is  inserted  into  the  greater  tubercle,  and 
into  the  cervix  humeri ;  the  fourth  is  the  subscapu-^ 
laris  muscle,  which  fills  up  the  venter,  or  inner  con- 
cave surface  of  the  scapula:  it  passes  over  the  inner 
side  of  the  head  of  the  bone,  and  is  fixed  to  the 
smaller  tubercle,  firmly  adhering  to  the  capsular  lig- 
ament as  it  passes  over  its  inferior  and  inner  surface* 
It  is  between  the  subscapularis  muscle,  and  the  teres 
minor,  that  the  capsular  ligament  is  found  of  great 
strength,  as  there  are  no  muscles  inserted  into  that 
part  to  protect  the  joint  from  injury. 

Muscles  of  motion  of  the  joint,  —  The  deltoid  mus- 
cle, the  coraco-brachialis,  and  the  teres  major,  which 
are  also  muscles  of  this  joint,  are  not  united  with 
the  capsular  ligament  as  the  other  muscles,  being 
only  destined  for  the  motion,  and  not  particularly  for 
the  protection  of  the  shoulder-joint. 

Tendon  of  the  biceps,  —  The  tendon  of  the  lon2: 
head  of  the  biceps  protects  the  upper  part  of  the 
joint,  where  it  otherwise  Avould  be  weak ;  for  this 
tendon  is  situated  between  that  of  the  supra-spinatus 


382 


STRUCTURE  OF  THE  SHOULDER-JOINT. 


and  subscapularis  :  it  arises  from  the  upper  point  of 
the  edge  of  the  glenoid  cavity  of  the  scapula,  and 
passes  over  the  head  of  the  bone  into  the  groove 
between  the  two  tubercles  and  the  portion  of  the 
capsular  ligament.  Reflected  towards  the  articular 
cartilage  of  the  os  humeri  it  adheres  to  the  surface 
of  this  tendon,  so  that  the  synovia  is  prevented  from 
escaping. 

Cause  of  the  frequent  dislocation  of  this  joint. — The 
shoulder-joint  has  a  greater  extent  and  variety  of 
motion  than  any  other  joint  in  the  body;  and  its 
dislocations  are,  consequently,  more  frequent  than 
those  of  all  the  other  joints  in  the  body  collective- 
ly :  those  of  the  ankle-joint  being  next  in  frequency. 


DISLOCATIONS  OF  THE  OS  HUMERI. 


Four  kinds  of  dislocation,  —  This  bone  is  liable  ta 
be  thrown  from  the  glenoid  cavity  of  the  scapula  in 
four  directions  ;  three  of  these  luxations  are  com- 
plete, and  one  is  only  partial. 

Downwards  and  inwards.  — The  first  is  downwards 
and  inwards ;  it  is  usually  called  the  dislocation  into 
the  axilla,  and  in  this  accident  the  bone  rests  upon 
the  inner  side  of  the  inferior  costa  of  the  scapula. 

Forwards.  —  The  second  is  forwards  upon  the 
pectoral  muscle,  when  the  head  of  the  os  humeri  is 
placed  below  the  middle  of  the  clavicle,  and  on  the 
sternal  side  of  the  coracoid  process. 

Backwards. — The  third  \s  {he  dislocation  back- 
wards, when  the  head  of  the  bone  can  be  both  felt 
and  distinctly  seen,  forming  a  protuberance  on  the 
back  and  outer  part  of  the  inferior  costa  of  the  sca- 
pula, and  situated  upon  its  dorsum. 

Partial  dislocations.  —  The  fourth  \s  only  partial, 
when  the  anterior  portion  of  the  capsular  ligament 
is  torn  through,  and  the  head  of  the  bone  is  found 
resting  against  the  coracoid  process  of  the  scapula, 
on  its  outer  side. 


384 


DISLOCATIONS   OF  THE  OS  HUMERI. 


Of  the  dislocation  upwards.  —  It  has  been  sup- 
posed that  a  dislocation  of  the  os  humeri  upwards 
might  occur,  but  it  is  obvious  that  this  could  only 
happen  under  fracture  of  the  acromion.  It  is  an  ac- 
cident which  I  have  never  seen. 

Dislocation  in  the  axilla.  —  Of  the  dislocation  in 
the  axilla  I  have  seen  a  multitude  of  instances;  of 
that  forwards  on  the  inner  side  of  the  coracoid  pro- 
cess several,  although  these  are  much  less  frequent 
than  that  in  the  axilla  ;  of  the  dislocation  backwards 
I  have  seen  only  two  instances  during  the  practice 
of  my  profession  for  thirty-eight  years.  1  do  not 
believe  in  any  change  of  place  after  dislocation, 
when  the  muscles  have  once  contracted  (except 
from  subsequent  violence,  which  is  very  uncommon), 
beyond  that  slight  change  which  pressure,  by  produc- 
ing absorption,  will  sometimes  occasion.  The  bone 
is  generally  at  once  thrown  into  the  situation  which 
it  afterwards  occupies;  so  that  excepting  from  cir- 
cumstances of  great  violence,  the  nature  and  direc- 
tion of  the  dislocation  are  not  subsequently  changed. 


DISLOCATION  IN  THE  AXILLA. 

Signs  of  dislocation  into  the  axilla.  —  The  usual 
sificns  of  this  dislocation  are  as  follow  :  A  hollow  is 
produced  below  the  acromion,  by  the  displacement 
of  the  head  of  the  humerus  from  the  glenoid  cavi- 
ty, and  the  natural  roundness  of  the  shoulder  is  de- 
stroyed, because  the  deltoid  muscle  is  flattened  and 
dragged  down  with  the  depressed  head  of  the  bone. 
The  arm  is  somewhat  longer  than  the  other,  as  the 
situation  of  the  bone  upon  the  inferior  costa  of  thesca- 
pula  is  below  the  level  of  the  glenoid  cavity.  The 
elbow  is  with  difficulty  made  to  touch  the  patient's 


DISLOCATIONS   OP  THE  OS  HUMERI. 


385 


side,  from  the  pain  produced  in  this  eiiort  by  pres- 
sure of  the  head  of  the  bone  upon  the  nerves  of 
the  axilla;  and  upon  this  account  it  usually  happens, 
that  the  patient  himself  supports  his  arm  at  the 
wrist  or  lore  arm  with  the  other  hand,  to  prevent 
its  weight  pressing  upon  these  nerves.  The  head 
of  the  0?  humeri  can  be  felt  in  the  axilla,  but  only 
if  the  elbow  be  considerably  removed  from  the  side. 
I  have  several  times  seen  surgeons  deceived  in  these 
accidents,  by  thrusting  the  fingers  into  the  axilla 
when  the  arm  is  close  to  the  side,  when  thej  have 
directly  said,  '  this  is  not  a  dislocation;'  but  upon 
raising  the  elbow,  the  head  of  the  bone  could  be 
distinctly  felt  in  the  axilla  ;  for  that  movement 
throws  the  head  of  the  bone  downwards  and  more 
into  the  axilla. 

The  motion  of  the  shoulder  is  in  a  great  degree 
lost,  more  especially  in  the  direction  upwards  and 
outwards,  for  the  patient  can  no  longer  raise  his  arm 
by  muscular  effort,  and  even  the  surgeon  generally 
finds  some  difficulty  in  overcoming  its  fixed  position; 
it  is  usual,  therefore,  as  a  first  question  in  detecting 
dislocation,  to  ask  the  patient  if  he  can  raise  his  arm 
to  his  head,  and  if  there  be  dislocation,  the  answer 
is  invariable  that  he  cannot.  The  power  of  rota- 
tion of  the  arm  is  also  lost ;  but  the  motion  of  the 
limb  forwards  and  backwards,  as  it  hangs  by  the 
side,  is  still  preserved.  There  is,  however,  great 
difference  in  respect  to  the  motion  of  the  limb,  and 
this  depends  upon  the  age  of  the  patient ;  in  old 
people,  the  relaxed  state  of  the  muscles  will  not 
only  admit  of  motion,  but  allow  the  surgeon  to  carry 
the  arm  to  the  upper  part  of  the  head.  On  mov- 
ing the  limb,  a  slight  crepitus  will  sonaetimes  be  felt 
from  inflammatory  effusion,  and  from  the  escape  of 
synovia,  but  by  the  continuance  of  the  motion 
this  soon  ceases ;  the  crepitus,  however,  in  these 

49 


386  DISLOCATIONS  OF  THE  OS  HUMERI. 


cases,  is  never  so  strong  as  that  which  a  fracture 
produces.  The  central  axis  of  the  arm  is  changed, 
for  the  central  h'ne  runs  into  the  axilla. 

In  this  accident,  numbness  of  the  fingers  frequent- 
ly occurs,  from  the  pressure  of  the  head  of  the 
bone  upon  a  nerve  or  the  nerves  of  the  axillary 
plexus. 

Circumstances  that  render  the  nature  of  the  accident 
difficult  to  ascertain, — These  are  the  circumstances 
of  greatest  moment ;  but  it  will  be  seen  that  the 
accident  can  be  detected  principally  by  the  fall  of 
the  shoulder,  by  the  presence  of  the  head  of  the 
bone  in  the  axillla,  and  by  the  loss  of  the  natural 
motions  of  the  joint.  But  a  few  hours  make  these 
appearances  much  less  decisive,  from  the  extravasa- 
tion of  blood,  and  from  the  excessive  swelling  which 
sometimes  ensue  ;  when,  however,  the  effused  blood 
has  become  absorbed,  and  the  inflammation  has  sub- 
sided, the  marks  of  fhe  injury  become  again  deci- 
sive. At  this  period  it  is  that  surgeons  of  the  me- 
tropolis are  usually  consulted;  and  if  we  detect  a 
dislocation  which  has  been  overlooked,  it  is  our 
duty,  in  candour,  to  state  to  the  patient,  that  the  diffi- 
culty in  the  detection  of  the  nature  of  the  accident 
is  exceedingly  diminished  by  the  cessation  of  inflam- 
mation, and  the  absence  of  tumefaction. 

Circumstances  that  render  it  easy.  —  It  may  be 
also  observed,  that  there  is  great  difference  in 
the  facility  with  which  the  accident  is  discovered 
in  thin  persons  of  advanced  age,  and  in  those 
who  are  loaded  with  fat,  or  who  have,  by  con- 
stant exertion,  rendered  their  muscles  excessively 
large. 


DISLOCATIONS  OF  THE  OS  HUMERI. 


387 


Dissection  of  the  Dislocation  into  the  Axilla. 

I  have  dissected  two  cases  of  recent  dislocation 
downwards.  A  sailor  fell  from  the  yard-arm  on  the 
ship's  deck,  injured  his  skull,  ar>d  dislocated  the  arm 
into  the  axilla.  He  was  brought  into  St  Thomas's 
Hospital  in  a  dying  state,  and  expired  immediately 
after  he  was  put  into  his  bed.  On  the  following  day  I 
obtained  permission  to  examine  his  shoulder,  which 
I  removed  from  the  body  for  the  purpose  of  obtain- 
ing a  more  minute  examination,  and  the  following 
were  the  appearances  which  I  found.  On  removing 
the  integuments,  a  quantity  of  extravasated  blood 
presented  itself  in  the  cellular  membrane,  lying  im- 
mediately under  the  skin,  and  in  that  which  covers 
the  axillary  plexus  of  nerves,  as  well  as  in  the  inter^ 
stices  of  the  muscles,  extending  as  far  as  the  cervix 
of  the  humerus,  below  the  insertion  of  the  subscapu- 
laris  muscle. 

^Appearances  upon  the  dissection  of  the  limb.  —  The 
axillary  artery,  and  plexus  of  nerves,  were  thrown  out 
of  their  course  by  the  dislocated  head  of  the  bone, 
which  was  pushed  backwards  upon  the  subsca[)ularis 
muscle.  The  deltoid  muscle  was  sunken  with  the 
head  of  the  bone.  The  supra  and  infra  spinatus 
were  stretched  over  the  glenoid  cavity  and  inferior 
costa  of  the  scapula.  The  teres  major  and  minor 
had  undergone  but  little  change  of  position;  but  the 
latter,  near  its  insertion,  was  surrounded  by  extrava- 
sated blood.  The  coraco-brachialis  was  uninjured. 
In  a  space  between  the  axillary  plexus  and  coraco- 
brachialis,  the  dislocated  head  of  the  bone,  covered 
by  its  smooth  articular  cartilage  and  by  a  thin  layer 
of  cellular  membrane,  appeared.  The  capsular  liga-^ 
ment  was  torn  on  the  whole  length  of  the  inner  side 
of  the  glenoid  cavity,  which  would  have  admitted 


388 


DISLOCATIONS   OF  THE  OS  HUMERI. 


a  much  larger  body  than  the  head  of  the  os  humeri 
through  the  opening.  The  tendon  of  the-subscapu- 
laris  muscle,  which  covers  the  hgament,  was  also  ex- 
tensively torn.  The  opening  of  the  ligament,  by 
which  the  tendon  of  the  long  head  of  the  biceps  pass- 
ed, was  rendered  larger  by  laceration,  but  the  ten- 
don itself  was  not  torn.  The  head  of  the  os  humeri 
was  thrown  on  the  inferior  costa  of  the  scapula,  be- 
tween it  and  the  ribs;  and  the  axis  of  its  new  situa- 
tion was  about  an  inch  and  a  half  below  that  of  the 
glenoid  cavity,  from  which  it  had  been  thrown. 

The  second  case  which  I  had  an  opportunity  of 
examining  was  one  in  which  the  dislocation  had  ex- 
isted five  weeks,  and  in  which  very  violent  attempts 
had  been  made  to  reduce  the  dislocated  bone,  but 
without  success.  The  subject  of  the  accident  was  a 
woman  fifty  years  of  age.  All  the  appearances 
were  distinctly  marked  ;  the  deltoid  muscle  being 
flattened,  and  the  acromion  pointed  ;  the  head  of 
the  hone  could  also  be  distinctly  felt  in  the  axilla; 
the  skin  had  been  abraded  during  the  attempts  at 
reduction,  and  the  woman  apparently  died  from  the 
violence  used  in  the  extension.  Upon  exposing  the 
muscles,  the  pectoralis  major  was  found  to  have  been 
slightly  lacerated,  and  blood  effused  ;  the  latissimus 
dorsi  and  teres  major  were  not  injured  ;  the  supra- 
spinatus  was  lacerated  in  several  places  ;  the  infra- 
spinatus and  teres  minor  w^ere  torn,  but  not  to  the 
same  extent  as  the  former  muscle.  Some  of  the 
fibres  of  the  deltoid  muscle  and  a  few  of  those  of 
the  coraco-brachia.lis  had  been  torn ;  but  none  of  the 
muscles  had  suffered  so  much  injury  as  the  supra- 
spinatus.    The  biceps  w^as  not  injured. 

Having  ascertained  the  injury  which  the  muscles 
had  sustained  in  the  extension,  and,  in  some  degree, 
the  resistance  which  they  opposed  to  it,  I  proceed- 
ed to  examine  the  joint. 


DISLOCATIONS   OP    THE  OS  HUMERI. 


389 


The  capsular  ligament  had  given  way  in  the  axil- 
la, between  the  teres  minor  and  subscapularis  mus- 
cles;  the  tendon  of  the  subscapularis  was  torn 
through  at  its  insertion  into  the  lesser  tubercle  of 
the  OS  humuri  (See  Plates)  ;  the  head  of  the  bone 
rested  upon  the  axillary  plexus  of  nerves  and  the 
artery.  Having  determined  these  points  by  dissec- 
tion, I  next  endeavoured  to  reduce  the  bone,  but 
finding  the  resistance  too  great  to  be  overcome  by 
my  own  efforts,  I  became  very  anxious  to  ascertain 
its  origin.  1  therefore  divided  one  muscle  after 
another,  cutting  through  the  coraca-brachialis,  teres 
major  and  minor,  and  infra  spinatus  muscles ;  yet 
still  the  opposition  to  my  efforts  remained,  and  with 
but  little  apparent  change.  I  then  conceived  that 
the  deltoid  must  be  the  chief  cause  of  my  failure, 
and  by  elevating  the  arm,  I  relaxed  this  muscle;  but 
still  could  not  reduce  the  dislocation.  I  next  divid- 
ed the  deltoid  muscle,  and  then  found  the  supra- 
spinatus  muscle  my  great  opponent,  until  I  drew  the 
arm  directly  upwards,  when  the  head  of  the  bone 
glided  into  the  glenoid  cavity.  The  deltoid  and 
supra-spinatus  muscles,  are  those  which  most  pow- 
erfully resist  reduction  in  this  accident. 

It  appears  from  these  dissections,  that  the  best 
direction  in  which  the  arm  may  be  extended  for  re- 
duction, is  at  a  right  angle  with  the  body,  or  direct- 
ly horizontall}^,  rather  than  obliquely  downwards; 
as  the  deltoid,  supra  and  infra  spinati  muscles,  are, 
in  this  position  of  the  limb,  thrown  into  a  relaxed 
state,  and  these  muscles  are,  as  I  have  explained, 
the  principal  sources  of  the  resistance.  The  biceps 
is  to  be  relaxed  by  slightly  bending  the  elbow. 
The  arm  may  be  extended  directly  outwards,  in  the 
line  between  the  pectoralis  major  on  the  outer  side, 
and  the  latissimus  dorsi  and  teres  major  on  the  in- 
ner ;  but  if  there  be  any  deviation  from  this  line,  it 


390 


DISLOCATIONS  OF  THE  OS  HUMERI. 


will  be  better  rather  to  advance  the  arm,  to  lessen 
the  power  of  the  pectoralis  major. 

This  dissection  explains  the  reason  why  the  arm 
is  sometimes  easily  reduced  soon  after  the  disloca- 
tion, by  raising  it  suddenly  above  the  horizontal 
line,  and  placing  the  fingers  under  the  head  of  the 
bone,  so  as  to  raise  it  towards  the  glenoid  cavity, 
which,  as  every  tyro  knows,  will  sometimes  prove 
effectual,  because,  in  this  position,  the  muscles  of 
opposition  are  relaxed  so  as  to  oppose  no  resistance 
to  reduction. 

Dissection  of  a  Dislocation  which  had  been  long  un- 

reduced. 

Dissection  of  an  old  dislocation,  —  The  head  of 
the  bone  is  found  altered  in  its  form  ;  the  surface 
towards  the  scapula  being  flattened,  a  complete  cap- 
sular ligament  covers  the  head  of  the  os  humeri. 
The  glenoid  cavity  is  completely  filled  by  ligament- 
ous matter,  infused  by  a  slow  inflammatory  process; 
in  this  ligamentous  matter  are  suspended  small  por- 
tions of  bone,  which  appear  to  be  of  new  formation, 
as  no  portion  of  the  scapula  or  humerus  is  broken; 
a  new  cavity  is  formed  for  the  head  of  the  os  hu- 
meri on  the  inferior  costa  of  the  scapula,  but  this 
is  glenoid,  like  that  from  which  the  os  humeri  had 
escaped.    (See  Plate.^ 

Causes  of  dislocation  into  the  axilla.  —  The  com- 
mon causes  of  dislocation  of  the  os  humeri  into  the 
axilla  are,  falls  upon  the  hand  while  the  arm  is 
raised  above  an  horizontal  line,  by  which  the  head 
of  the  bone  is  thrown  downwards;  also  a  fall  upon 
the  elbow,  when  the  arm  is  raised  from  the  side; 
but  the  most  frequent  cause  is  a  fall  directly  upon 
the  shoulder  on  some  uneven  surface,  by  which  the 


DISLOCATIONS   OF  THE  OS   HUMERI.  391 

head  of  the  bone  is  driven  downwards,  whilst  the 
muscles   are  but  ill  prepared  to  resist  the  shock. 

Frequency  of  its  recurrence.  —  When  the  arm  has 
been  once  dislocated,  if  great  care  be  not  taken  of 
the  limb  after  its  reduction,  it  is  extremely  liable  to 
a  recurrence  of  the  accident.  I  remember,  parti- 
cularly, a  carpenter,  who  used  to  be  a  frequent 
visiter  at  Guy's  Hospital  for  several  years,  for  the 
purpose  of  having  his  shoulder  reduced.  Slighter 
causes  than  that  which  originally  produced  it,  will 
renew  the  dislocation;  I  have  known  it  to  recur 
from  the  act  of  throwing  up  the  sash  of  a  window. 
During  my  apprenticeship  at  St  Thomas's  Hospital, 
in  going  through  the  wards  early  one  morning,  I 
was  directed  to  see  a  man  who  had  just  dislocated 
the  shoulder,  which  he  had  frequently  done  before, 
as  he  was  lying  in  bed;  and  upon  inquiring  how  it 
had  happened,  the  man  replied,  that  it  occurred 
merely  in  the  effort  of  rubbing  his  eyes  and  stretch- 
ing himself  upon  waking;  but  this  disposition  to  the 
recurrence  of  dislocation  may  be  prevented,  by  di- 
recting that  the  arm  be  kept  fixed  close  to  the  side, 
and  the  shoulder  rather  elevated  by  a  pad  in  the 
axilla,  for  three  weeks  after  its  reduction  ;  during 
which  time  the  ruptured  tendon  of  the  subscapularis, 
and  the  capsular  ligament  will  be  united:  a  process 
which  motion  greatly  impedes,  if  not  wholly  pre- 
vents. 


Reduction  of  the  Dislocation  in  the  Axilla, 

Means  employed  for  reduction,  —  Various  have 
been  the  means  suggested  for  the  reduction  of  the 
head  of  the  humerus,  when  dislocated  downwards 
into  the  axilla  ;  but  under  the  different  circumstances 
attending  this  accident,  different  means  must  be  em- 


392 


DISLOCATIONS  OF  THE  OS  HUMERI. 


ployed  ;  the  first,  and  that  which  I  usually  adopt  in 
my  private  practice  in  all  recent  cases,  is 

By  the  Heel  in  the  Axilla : 
And  the  best  mode  of  its  application  is  as  follows  : 
The  patient  should  be  placed  in  the  recumbent 
posture,  upon  a  table  or  a  sofa,  near  to  the  edge  of 
which  he  is  to  be  brought ;  the  surgeon  then  binds 
a  wetted  roller  round  the  arm  immediately  above 
the  elbow,  upon  which  he  ties  a  handkerchief ;  then 
with  one  foot  resting  upon  the  floor,  he  separates 
the  patient's  elbow  from  his  side,  and  places  the 
heel  of  his  other  foot  in  the  axilla,  receiving  the 
head  of  the  os  humeri  upon  it,  whilst  he  is  himself 
in  the  half  sitting  posture  by  the  patient's  side.  He 
then  draws  the  arm  by  means  of  the  handkerchief, 
steadily  for  three  or  four  minutes,  when,  under  com- 
mon cfrcumstances,  the  head  of  the  bone  is  easily 
replaced  (^see  Plate):  but  if  more  force  be  required, 
the  handkerchief  may  be  changed  for  a  long  towel, 
by  which  several  persons  may  pull,  the  heel  still  re- 
maining in  the  axilla.  I  generally  bend  the  fore  arm 
nearly  at  right  angles  with  the  os  humeri,  because 
it  relaxes  the  biceps,  and  consequently  diminishes 
its  resistance.  I  have,  in  many  cases,  extended  from 
the  wrist,  by  tying  the  handkerchief  just  above  the 
hand,  but  more  force  is  required  in  this  than  in  the 
former  mode,  although  it  has  this  advantage,  that 
the  bandage  is  less  liable  to  slip.  In  recent  cases 
it  very  rarely  happens  that  this  mode  of  extension 
fails,  and  it  is  so  easily  applied  in  every  situation, 
that  I  have  recommended  all  our  young  men  to 
employ  it  in  the  first  instance,  when  called  to  this 
accident. 

Second  Mode. 
Second  mode  ;  application  of  the  bandage,  —  But 


DISLOCATIONS  OF  THE  OS  11U3IERI.  393 

in  those  casqs  in  which  (he  muscles  are  of  very  consid- 
erable strength,  and  the  dislocation  having  existed 
for  several  days,  the  muscles  have  become  perma- 
nently contracted,  so  that  the  limb  is  strongly  fixed 
in  its  new  situation,  more  force  is  required,  and  the 
following  means  should  be  employed.  The  patient 
must  be  placed  upon  a  chair,  and  the  scapula  fixed 
by  means  of  a  bandage,  which  allows  the  arm  to 
pass  through  it;  that  which  we  use  at  our  hospital 
is  a  girt  buckled  on  the  top  of  the  acromion,  so  as  to 
raise  the  bandage  high  in  the  axilla,  and  thus  enable 
it  more  completely  to  fix  the  scapula,  which  is  the 
principal  object  to  be  attended  to,  as  otherwise  all  ef- 
forts will  be  inefficient.  When  I  first  saw  the  mode 
of  reduction  practised  thirty-eight  years  ago,  a  round 
towel  was  used  instead  of  this  bandage,  which  was 
placed  in  the  axilla,  and  crossed  the  chest,  but  it  ap- 
peared to  me  that  by  this  means  the  lower  angle  of 
the  scapula  alone  was  fixed,  and  that  the  glenoid  ca- 
vity was  drawn  with  the  arm  when  extension  was 
made;  I  directed,  therefore,  that  the  towel  should 
be  tied  over  the  opposite  shoulder  with  a  handker- 
chief, so  that  it  should  be  raised  in  the  axilla  on  the 
injured  side,  and  thus  embrace  a  larger  surface  of 
the  scapula;  but  still  I  found  the  scapula  drawn  from 
the  side  with  the  arm,  and  therefore  had  the  ban- 
dage made  as  described  (sec  Plate),  A  wetted  j'oller 
is  next  to  be  bound  around  the  u[)per  arm  just  above 
the  elbow,  from  which  situation  it  cannot  slip,  and 
upon  this  a  very  strong  worsted  tape  is  to  be  fasten- 
ed, in  a  manner  to  be  described,  when  speaking  of 
the  reduction  of  dislocated  fino^ers.  The  arm  should 
then  be  raised  at  right  angles  with  the  body,  and  if 
there  be  much  difficulty  in  the  reduction,  it  should  be 
elevated  above  the  horizontal  line,  more  completely 
to  relax  the  deltoid  and  supra-spinatus  muscles. 
Two  persons  should  then  draw  from  the  bandage 

50 


394 


DISLOCATIONS  OF  THE  OS  HUMERI. 


affixed  to  the  arm,  and  two  from  the  scapula  band- 
.agc,  with  a  steady,  equal,  and  conibined  force  ;  jerk- 
ing should  be  entirely  avoided,  and  every  aim  at 
quick  reduction  should  be  discountenanced :  'slowly 
and  steadily''  should  be  the  word  of  command  from 
the  surgeon  •  who,  after  the  extension  has  been  kept 
up  for  a  few  minutes,  sho  Id  place  his  knee  in  the 
axilla,  resting  his  foot  on  the  chair  upon  which  the 
patient  sits  ;  he  should  then  raise  his  knee  by  extend- 
ing his  foot,  and  placing  his  right  hand  upon  the 
acromion,  push  it  downwards  and  inwards,  when  the 
head  of  the  bone  will  usually  slip  into  its  natural  po- 
sition. Whilst  the  extension  is  proceeding  I  have 
seen  a  gentle  rotatory  motion  of  the  arm  diminish  op- 
position of  the  muscles,  and  the  bone  suddenly  slip 
into  its  place. 

But  when  a  limb  has  remained  a  considerable 
length  of  time  dislocated;  when  the  muscles  are  so 
powerfully  contracted  that  the  force  of  men  cannot 
be  so  steadily  exerted  as  to  reduce  the  limb,  after 
several  attempts,  the  minds  and  bodies  of  the  assist- 
ants becoming  fatigued,  and  their  efforts  violent  and 
unequal^  then  we  employ  the  third  mode  of  reduc- 
tion, 

By  means  of  the  Pidleys, 
Pulleys  ;  application  of  the  pulley^  8fc,  —  And  here 
let  it  be  understood  that  they  are  not  adopted  with 
a  view  of  employing  greater  force,  for  that  might 
be  obtained  by  the  aid  of  more  persons ;  but  they 
are  introduced  to  enable  the  surgeon  to  employ  the 
force  gradually  and  equally  ;  to  avoid  jerks  and 
unequal  extension,  which,  in  protracted  cases,  the 
efforts  of  men  are  sure  to  produce.  If,  therefore, 
1  saw  a  surgeon,  as  soon  as  the  pulleys  were  fixed, 
draw  them  violently,  and  endeavour  suddenly  to  re- 
duce the  limb,  I  should  not  hesitate  at  once  to  say, 


DISLOCATIONS  OF  THE  OS  HUMERI. 


395 


*that  genlleman  is  ignorant  of  the  principle  upon 
which  this  mechanical  power  is  employed,  and  has 
still  this  part  of  his  profession  to  lear  n:  For  the 
application  of  the  pulley  the  patient  is  seated  be- 
tween two  staples,  which  are  screwed  into  the  wain- 
scot on  each  side  of  him;  the  bandages  are  then 
applied,  precisely  as  in  the  former  mode,  in  which 
the  extension  is  performed  by  men,  and  the  force 
is  applied  in  the  same  direction  ;  the  surgeon  should 
first  draw  the  pulky,  as  the  class  of  people  usually 
summoned  to  his  assistance,  being  ignorant  of  the 
principle  upon  which  it  is  employed,  would  use  too 
great  violence  ;  he  should  draw  gently  and  steadily, 
until  the  patient  begins  to  complain  of  pain,  and 
then  cease,  keeping  up  the  degree  of  extension,  and 
conversing  with  the  patient  to  direct  his  mind  to 
other  objects.  In  two  or  three  minutes,  more  force 
should  be  applied,  and  continued  until  pain  be  again 
complained  of,  when  the  surgeon  should  again  cease 
to  increase  the  force;  and  thus  he  should  proceed 
for  a  quarter  of  an  hour,  at  intervals  slightly  rotat- 
ing the  limb.  He  should,  when  he  has  applied  all 
the  extension  he  thinks  right,  give  the  string  of  the 
pulley  to  an  assistant,  desiring  the  existing  degree 
of  extension  to  be  supported;  then,  putting  his  knee 
in  the  axilla,  and  resting  his  foot  upon  the  chair,  he 
should  gently  raise  and  push  back  the  head  of  the 
bone  towards  the  glenoid  cavity,  when  the  bone  will 
pass  into  its  socket;  this  takes  place  generally  with- 
out the  snap  which  is  heard  when  other  means  are 
employed,  yet  both  the  surgeon  and  the  patient  are 
aware  of  some  motion  of  the  head  of  the  bone  at 
the  time.*    If  the  |)ulleys  be  thus  employed,  the 

*  Oae  of  our  pupils,  a  Mr  Bartlett,  of  Ipswich,  has  invented 
n  small  spring,  by  means  of  which  the  strings  are  attached  to 
the  pulley,  and  which  can  certainly  detach  them  whilst  the 


396 


DISLOCATIONS   OF  THE  OS  HUMERI. 


extension  will  be  conducted  infinitely  more  steadily 
and  elfectuaUv  tlian  when  performed  by  men.  In 
,my  hospital  practice  I  order  the  patient  to  be  bled, 
and  to  be  put  into  a  warm  bath  at  the  temperature 
ol*  100  to  110°;  and  I  give  him  a  grain  of  tartariz- 
ed  antimony  every  ten  minutes  until  he  becomes 
faint ;  then  I  order  him  to  be  removed  from  the 
bath,  to  be  wrapped  in  a  blanket,  and  immediately 
placed  upon  the  chair  for  extension,  before  his  mus- 
cles have  had  time  to  recover,  which  expedient 
lessens  the  necessity  of  employing  very  considerable 
force.  Mr  Henry  Cline,  Surgeon  to  St  Thomas's 
Hospital,  son  to  my  most  excellent  master,  and  who 
would  have  made  an  excellent  practical  surgeon  if 
the  hand  of  death  had  not  prematurely  deprived 
the  world  of  his  useful  talents,  was  in  the  habit  of 
directing  his  patients  to  support  a  weight  for  a  length 
of  time  before  the  extension  was  begun,  with  a  view 
of  fatiguing  the  muscles,  and  lessening  their  power 
of  resistance.  In  apartments  where  it  is  not  con- 
venient to  place  the  pulleys  in  the  walls,  I  have  fix- 
ed them  in  the  floor,  on  each  side  the  patient,  who 
must,  under  these  circumstances,  sit  upon  the  floor. 
When  the  reduction  has  been  efl*ected,  a  small  cush- 
ion should  be  placed  in  the  axilla,  and  fixed  there 
by  a  stellate  bandage,  to  prevent  the  head  of  the 
bone  from  again  slipping  out  of  its  situation,  which 
the  excessive  relaxation  of  the  muscles  would  readi- 
ly permit ;  but  the  cushion  should  not  be  so  large 
as  to  separate  the  arm  far  from  the  side.  The  sling 
is  to  be  also  worn  to  support  the  arm. 

There  is  still  a  fourth  mode  of  reducing  the  dis- 
location into  the  axilla,  which  is  applicable  to  recent 

knee  is  in  the  axilla.  This  instrument  may  sometimes  be 
useful.  —  A.  C. 


DISLOCATIONS   OF  THE  OS  HUMERI. 


397 


dislocations,  to  delicate  females,  and  to  very  old,  re- 
laxed, and  emaciated  peisons,  viz  : 

By  the  Knee  in  the  Axilla. 
Fourth  mode  of  reduction.  —  The  patient  is  seat- 
ed upon  a  low  chair,  the  surgeon  placing  himself 
by  him,  separates  the  dislocated  arm  from  the  side 
sufficiently  to  admit  his  knee  into  the  axilla,  and 
resting  his  foot  upon  the  side  of  the  chair,  he  plac- 
es one  hand  upon  the  os  humeri,  just  above  the  con- 
dyles, and  the  other  upon  the  acromion  scapulas;  he 
then  pulls  down  the  arm  over  the  knee,  and  in  this 
manner  reduces  the  dislocation.  {See  Plate.')  Even 
in  persons  of  powerful  muscles,  1  have  known  this 
mode  succeed,  when  the  patient  remained  in  the 
state  of  intoxication  in  which  he  was  found  Avhen 
the  accident  happened. 

The  use  of  the  Ambe, — The  ambe  has  been  re« 
commended  for  the  reduction  of  dislocations  in  the 
axilla,  and  this  instrument  was,  in  the  last  century,, 
improved  by  the  addition  of  a  screw  for  the  pur- 
pose of  rendering  its  extension  more  gradual.  It 
may  succeed  very  well  in  recent  cases,  and  in  those 
persons  whose  muscles  are  not  very  powerful ;  but 
when  a  continued  extension  must  of  necessity  be 
used  to  reduce  the  bone,  as  its  fixed  point  of  action 
is  upon  the  ribs  of  the  patient,  it  produces  too  much 
injury  to  the  side,  is  too  painful  to  be  borne  long, 
and  is,  therefore,  an  instrument  which  cannot  be  re- 
commended for  general  use. 

Mr  Kirby,  surgeon  in  Dublin,  has  lately  advised 
an  ingenious  mode  of  applying  force  in  dislocations 
of  the  shoulder:  the  scapula  being  fixed  and  the 
bandage  applied  to  the  arm,  the  patient  sits  upon  a 
mattress  which  is  laid  upon  the  floor,  and  the  assist- 
ants, to  whose  management  the  extension  and  coun- 
ter-extension are  consigned,  place  themselves  at  his 


398 


DISLOCATIONS   OF  THE  OS  HUMERI. 


side,  sitting  opposite  to  each  other,  and  disposing 
their  legs  so  that  the  soles  of  their  feet  are  oppos- 
ed to  each  other,  behind  and  before  the  patient. 
If  occasion  should  require  a  greater  force  than  the 
power  of  two  men,  another  assistant  or  more  may 
be  placed  at  the  backs  of  the  first  two,  sitting  close 
up  to  them  with  their  faces  turned  towards  the  pa- 
tient;, the  extension  is  now  made,  with  the  arm 
raised  nearly  to  a  right  angle  with  the  body,  and  in 
the  direction  forwards  or  backwards,  as  the  circum- 
stances of  the  case  may  require.  The  force  should 
be  maintained  until  it  is  perceived  that  the  head  of 
ihe  bone  (which  can  be  easily  felt,  and  should  be 
pressed  upon  during  the  operation),  has  moved  from 
its  new  situation  ;  and  when  the  head  of  the  bone 
Is  found  to  change  its  position,  the  assistants  should 
slowly  diminish  their  force  while  the  surgeon  directs 
it  towards  the  glenoid  cavity,  by  pressing  the  elbow 
to  the  side  of  the  patient  and  slightly  raising  it. 

Slight  force  necessary  fir  reductions  after  repeated 
dislocation.-^  When  a  person  has  frequently  dislo- 
cated his  shoulder,  a  very  slight  effort  is  sufficient 
to  restore  the  limb  to  its  place;  and  I  know  a  gen- 
tleman in  the  country  who  has  frequently  returned 
the. dislocated  head  of  the  humerus  into  its  situation, 
by  walking  up  to  a  gate,  reaching  over  as  far  as  he 
could,  and  then  holding  by  one  of  its  lowest  bars, 
the  upper  bar  of  the  gate  being  pressed  firmly  into 
the  axilla;  still  retaining  his  hold,  he  suffers  his 
body  to  sink  on  the  other  side  of  the  gate,  and  the 
head  of  the  bone  is  thus  pushed  into  the  glenoid 
cavity;  this  mode  of  reduction  is  the  same  in  prin- 
ciple as  that  of  the  heel  in  the  axilla,  which,  as  I 
have  already  mentioned,  in  three-fourths  of  recent 
dislocations,  is  the  best  for  effecting  the  reduction. 


DISLOCATIONS  OF  THE   OS  HUMERI. 


399 


DISLOCATION  FORWARDS,  BEHIND    THE  PECTORAL  MUS- 
CLE, AND  BELOW  THE  MIDDLE   OF  THE  CLAVICLE. 

Symptoms ;  situation  of  the  head  of  the  humerus, 
—  This  species  of  dislocation  is  much  more  distinct- 
ly marked  than  the  former.  The  acromion  is  more 
pointed,  and  the  hollow  below  it,  from  the  depres- 
sion of  the  deltoid  muscle,  is  much  more  consider- 
able. The  head  of  the  os  humeri  can  be  readily 
and  distinctly  felt,  and  even  seen,  in  thin  persons, 
just  below  the  clavicle  ;  and  when  the  arm  is  rotat- 
ed from  the  elbow,  the  protuberance  may  be  seen 
to  obey  the  motions  of  the  arm. 

The  coracoid  process  of  the  scapula  is  placed  oh 
the  outer  side  of  the  head  of  the  bone,  so  that  the 
latter  is  situated  between  the  scapula  and  the  ster- 
num, and  is  covered  by  the  pectoralis  major  muscle. 
The  arm  is  somewhat  shortened,  and  the  elbow  is 
thrown  more  from  the  side,  and  further  back,  than 
in  dislocation  into  the  axilla.  (See  Plate.)  The  axis 
of  the  limb  is  much  altered,  being  thrown  inward 
towards  the  middle  of  the  clavicle. 

The  degree  of  pain  in  this  accident,  S^c.  —  The 
pain  attending  this  accident  is  slighter  than  when 
the  head  of  the  os  humeri  is  thrown  into  the  axilla, 
because  the  nerves  of  the  axillary  plexus  are  less 
compressed ;  but  the  motions  of  the  joint  are  much 
more  materially  affected;  the  head  of  the  bone  be- 
coming fixed  by  the  coracoid  process,  and  neck  of 
the  scapula,  on  the  outside,  and  by  the  clavicle  above ; 
while  the  muscles  of  the  scapula,  as  the  supra  and 
infra  spinati,  and  teres  minor,  being  put  upon  the 
stretch,  confine  all  its  motions  inwards  and  back- 
wards. If,  therefore,  the  arm  be  attempted  to  be 
brought  forwards,  the  head  of  the  bone  strikes 
against  the  clavicle;  if  outwards,  from  the  side,  the 


400 


DISLOCATIONS  OF  THE  OS  HUMERI. 


coracoid  process  stops  it :  its  motion  backwards, 
however,  is  confined,  not  bj  bone,  but  by  the  resist- 
ance of  muscles.  But  the  strongest  diagnostic  marks 
of  this  dislocation  are  these  :  the  head  of  the  bone 
is  below  the  clavicle;  the  elbow  is  separated  from 
the  side,  and  thrown  backwards ;  and  the  rotation 
of  the  arm  gives  motion  to  the  head  of  the  bone 
under  the  clavicle. 


Dissection  of  the  Dislocation  Forwards. 

Os  humeri;  appearances  on  dissection,  —  The  head 
of  the  OS  humeri  is,  in  this  accident,  thrown  on  the 
inner  side  of  the  neck  of  the  scapula,  between  it 
and  the  second  and  third  ribs.  I  have  had  no  op- 
portunity of  dissecting  a  recent  accident  of  this 
kind;  but  in  the  Museum  at  St  Thomas's  Hospital 
there  is  a  beautiful  specimen  of  one  in  a  limb  which 
had  been  long  dislocated,  and  which  was  removed 
from  the  shoulder  of  a  patient  by  Mr  Green,  and 
dissected  by  Mr  Key,' who  gave  me  the  following 
account  of  the  appearances;  —  The  head  of  the 
bone  was  thrown  on  the  neck  and  part  of  the  ven- 
ter of  the  scapula,  near  the  edge  of  the  glenoid 
cavity,  and  immediately  under  the  notch  of  the  su- 
perior costa :  nothing  intervened  between  the  head 
of  the  humerus  and  scapula,  the  subscapularis  being 
partly  raised  from  its  attachment  to  the  venter. 
The  head  was  situated  on  the  inner  side  of  the  co- 
racoid process,  and  immediately  under  the  edge  of 
the  clavicle,  without  having  the  slightest  connexion 
with  the  ribs ;  indeed,  this  must  have  been  prevent- 
ed, by  the  situation  of  the  subscapularis  and  serratus 
magnus  muscles  between  the  thorax  and  humerus. 
The  tendons  of  all  the  muscles  attached  to  the  tu- 
bercles of  the  humerus  were  perfect,  and  are  shown 


DISLOCATIONS   OP  THE  OS  HUMERI.  401 


in  the  preparation.  The  tendon  of  the  biceps  was 
not  torn;  and  it  adhered  to  the  capsular  ligament. 
The  glenoid  cavity  was  completely  filled  up  by  liga- 
mentous structure;  still,  however,  preserving  its 
general  form  and  character.  Tiic*  tendons  of  the 
supra  and  infra  spinatus,  and  teres  minor  muscles, 
adhered  by  means  of  bands  to  the  ligamentous  struc- 
ture occupying  the  glenoid  cavity  :  and  to  prevent 
the  effects  of  friction  between  the  tendons  and  the 
glenoid  cavity  in  the  motions  of  the  arm,  a  sesamoid 
bone  had  been  formed  in  the  substance  of  the  ten- 
dons. The  newly  formed  socket  reached  from  the 
edge  of  the  glenoid  cavity  to  about  one  third  across 
the  venter.  A  complete  lip  was  formed  around  the 
new  cavity,  and  the  surface  was  irregularly  covered 
with  cartilage.  The  head  had  undergone  consider- 
able change  of  form,  the  cartilage  being  in  many 
places  absorbed.  A  complete  new  capsular  ligament 
had  been  formed.    (^See  Plate.) 

The  pectorah's  minor  is  not  mentioned  in  this  dis- 
section ;  but  from  the  natural  situation  of  the  cora- 
coid  process,  into  which  this  muscle  is  inserted,  it 
must  have  passed  over  the  head  of  the  os  humeri, 
as  did  the  pectoralis  major. 

Causes  of  this  dislocation.  —  The  usual  causes  of 
this  dislocation  are,  either  a  fall  upon  the  elbow,  or 
a  violent  blow  upon  the  shoulder,  as  in  the  last  de- 
scribed dislocation.  If  it  be  a  blow  upon  the  elbow 
which  has  produced  the  accident,  it  must  have  been 
inflicted  at  a  time  when  the  elbow  was  thrown  be- 
hind the  central  line  of  the  body  ;  and  w'hen  the 
shoulder  received  the  blow,  the  head  of  the  bone 
must  have  been  driven  forwards  and  inwards. 


402  DISLOCATIONS   OF  THE  OS  HUMERI. 


Reduction  of  the  Dislocation  Forwards, 

In  this,  as  In  the  former  case,  we  can  usually  suc- 
ceed In  effecting  reduction  by  placing  the  foot  in  the 
axilla,  and  by  extending  the  arm  in  the  same  man- 
ner; excepting  that  in  this  dislocation,  the  foot  is 
required  to  be  brought  more  forward  to  press  on  the 
head  of  the  bone,  and  the  arm  should  be  drawn 
obliquely  downwards,  and  a  little  backwards;  but 
in  those  cases  in  which  some  days  have  elapsed  be- 
fore reduction  has  been  attempted,  continued  exten- 
sion will  be  necessary  ;  and,  to  employ  rt  steadily 
and  effectually,  the  pulleys  should  be  used. 

The  same  bandage  is  required  as  in  the  disloca-  ■ 
tion  in  the  axilla,  whether  the  power  used  be  applied 
through  the  medium  of  pulleys  or  directly  by  men. 
The  arm  should  be  bent  to  relax  the  biceps  mus- 
cle ;  but  the  principal  circumstance  to  be  consider- 
ed is,  the  direction  in  which  the  bone  is  to  be  dravYn, 
and  the  best  direction  is  slightly  downiwards;  for  if 
it  be  drawn  horizontally,  the  head  of  the  os  humeri 
is  pulled  against  the  coracoid  process  of  the  scapula, 
and  a  difficulty  created  which  may  be  avoided.  The 
principle  upon  which  the  pulley  is  employed,  and 
the  manner  in  which  the  extension  is  supported,  is 
the  same  as  in  the  dislocation  into  the  axilla,  btit  the 
direction  is  different,  the  arm  being  drawn  obliquely 
downwards  and  backwards.  The  extension  must  be 
kept  up  longer  than  in  the  dislocation  downwards, 
as  the  resistance  is  greater  :  but  as  soon  as  the  bone 
is  felt  to  move  from  its  situation,  the  surgeon  should 
give  the  strings  of  the  pulley  to  an  assistant,  and 
putting  his  knee  or  heel  against  the  head  of  the 
bone  at  the  fore  part  of  the  shoulder,  should  push  it 
back  towards  the  glenoid  cavity  :  but  this  step  is  not 
of  the  smallest  utility  until  the  bone  has  been  drawn 


DISLOCATIONS  OF   THE   OS  HUMERI. 


403 


below  the  level  of  the  coracoid  process:  and  whilst 
the  surgeon  is  thus  pressing  the  head  of  the  bone 
backwards,  he  should  pull  the  arm  forwards  from 
the  elbow.  This  is  the  plan  which  I  have  found  by 
far  the  most  effectual  in  reducing  the  dislocation 
forwards. 


DISLOCATION   OF  THE   OS  HUMERI   ON  THE  DORSUM 
SCAPULiE. 


Diagnostic  signs.  —  In  this  dislocation,  the  head 
of  the  bone  is  thrown  upon  the  posterior  surface  of 
the  inferior  costa  of  the  scapula.  It  is  an  accident 
which  cannot  be  mistaken,  as  there  is  a  protuberance 
formed  by  the  bone  upon  the  scapula,  which  imme- 
diately strikes  the  eye;  and  when  the  elbow  is  ro- 
tated, this  protuberance  rolls  also.  The  dislocated 
head  of  the  bone  may  be  easily  grasped  between  the 
fingers,  and  distinctly  felt  resting  below  the  spine  of 
-the  scapula  ;  the  motions  of  the  arm  are  impaired,  but 
not  to  the  same  extent  as  in  either  of  the  other 
states  of  luxation, 

Tke  unfrequent  occurrence  of  this  accident.  —  Two 
cases  of  this  accident  have  occurred  in  Guy's  Hos- 
pital in  thirty-eight  years  ;  the  first  during  my  ap- 
prenticeship. It  happened  during  the  anatomical 
lecture  at  St  Thomas's  Hospital.  The  surgery-man 
came  to  the  theatre  and  announced  that  there  was  a 
dislocation  of  the  shoulder  at  Guy's  Hospital,  when  Mr 
Cline  went  over  with  the  students  to  see  the  acci- 
dent, and  met  Mr  Forster,  under  whose  care  the  pa- 
tient was  admitted.  The  nature  of  the  accident 
was  at  once  obvious,  from  the  projection  of  the  head 
of  the  bone  on  the  dorsum  scapulte.    The  bandages 


404 


DISLOCATIONS  OF  THE   OS  HUMERI. 


were  applied  in  the  same  manner  as  if  the  head  of 
the  humerus  had  been  in  the  axilla,  and  the  exten- 
sion was  made  in  the  same  direction  as  in  that  acci- 
dent. During  the  progress  of  the  adjustment  of  the 
apparatus,-some  conversation  took  place  between  Mr 
Cline  and  Mr  Forster,  as  to  what  variation  in 
direction  there  should  be  given  to  the  bone,  if  the 
first  attempt  should  not  succeed;  but  in  less  than 
five  minutes,  the  bone  slipped  into  the  glenoid  cavitj 
with  a  loud  snap. 

Tlie  second  case,  which  occurred  several  years 
after,  was  easily  reduced  by  the  dressers  under  the 
same  treatment. 


Mr  Toulmin,  of  Hackney,  has  had  the  kindness  to 
send  me  the  following  communication  upon  the  sub- 
ject of  this  species  of  dislocation. 

Mr  Tonhniri's  case.  —  My  dear  Sir  :  —  The  gen- 
tleman to  whom  the  dislocation  of  the  head  of  the 
humerus  upon  the  dorsum  scapulae  occurred,  was 
Mr  CoHinson,  who  was  about  thirty-six  years  of  age, 
six  feet  higli,  and  unusually  muscular.  The  injury 
was  sustained  in  the  neighbourhood  of  Windsor,  in 
consequence  of  his  horse  I'alling  with  him,  by  which 
he  was  thrown  over  the  animal's  head.  He  applied 
to  a  surgeon  at  Windsor,  but  the  character  of  the 
accident  was  not  detected.  He  returned  in  a  post- 
chaise  to  his  own  liouse,  when  Mr  Hacon  and  myself 
saw  him.  The  shoulder  had  lost  its  natural  round- 
ness :  the  arm  could  be  moved  considerably,  either 
upwards  or  downwards;  but  the  motion,  either  in  the 
anterior  or  posterior  direction,  was  very  limited.  On 
raising  the  arm  to  a  right  angle  with  the  side,  the 
direction  of  the  limb  was  obviously  behind  the  gle- 
noid cavity ;  and  by  placing  the  hand  over  the 
dorsum  scapultc,  and  then  rotating  the  arm,  the  head 
of  the  bone  was  felt  to  obey  the  rotating  motion. 


DISLOCATIONS   OF   THE   OS  HUMERI. 


405 


Means  employed  for  its  reduction.  —  In  order  to 
reduce  this  dislocation,  a  large  towel  was  applied  to 
sustain  the  necessary  force  for  the  reduction,  and  to 
fix  as  much  as  possible  that  part  of  the  scapula  un- 
occupied by  the  head  of  the  bone.  A  gradual  ex- 
tension of  the  limb  was  made  directly  outwards,  and 
then  the  arm  being  slowly  moved  lor  wards,  the  head 
of  the  bone  was  distinctly  heard  to  snap  into  its 
socket.  The  extension  was  not  continued  for  more 
than  two  or  three  minutes  before  the  reduction  was 
accomplished.  To  the  best  of  my  recollection,  Mr 
Collinson-3  arm  was  perfectly  restored  to  all  its 
functions  within  a  month. 

1  am,  my  dear  Sir, 

Very  truly  your's. 
Hackney.,  Jidy  10,  1822.  J.  Toulmin. 


I  have  also  received  the  following  remarks  on  the 
dislocation  of  the  os  humeri  backwards,  from  Mr  C. 
M.  Coley,  of  Bridgenorth. 

May  Wth,  1822. 
My  dear  Sir:  —  The  dislocation  of  the  shoulder 
backwards  is  very  rare,  and  I  apprehend,  imperfect- 
ly understood  and  described  by  surgical  writers. 
The  external  appearances  are  a  hollow  and  pucker- 
ing of  the  parts  just  below  the  acromion;  the  arm 
lies  close  to  the  side  ;  the  fore  arm  is  turned  inwards, 
and  passes  obliquely  forwards  across  the  body;  a 
protuberance  as  large  as  an  orange  is  seen  on  the 
dorsum  scapula?,  close  to  the  spine  of  that  bone. 
This  dislocation  is,  I  suppose,  produced  by  the  action 
of  the  teres  major  and  latissimus  dorsl  upon  the  bone, 
while  its  head  is  forced  over  the  margin  of  the  gle- 
noid cavity. 

Reduction.  —  The  reduction  is  effected  by  elevat- 


406 


DISLOCATIONS  OF  THE  OS  HUMERI. 


ing  the  arm  and  rotating  it  outwards,  so  as  to  roll 
the  head  of  the  humerus  towards  the  axilla;  having 
brought  it  as  much  as  possible  to  resemble  a  disloca- 
tion into  the  axilla,  the  operator  must  keep  it  in  that 
situation,  and,  at  the  same  time,  bring  down  the  arm 
in  an  horizontal  direction,  when,  an  extending  force 
being  applied,  the  bone  will  be  readily  reduced. 

Case.  — July  17th,  1820.  Thomas  Aiding,  of  this 
town,  was  pulled  down  by  a  calf  which  he  was 
driving,  a  cord  having  been  tied  to  one  of  the  calf's 
legs,  and  held  fast  by  the  man's  hand.  The  ap- 
pearances corresponded  with  the  above  described 
general  marks  of  the  accident. 

JVleans  of  reduction  employed,  —  I  rotated  the  fore 
arm  as  much  as  possible  outward,  carrying  the  whole 
arm  upwards  at  the  same  time,  so  that  the  hand 
was  brought  nearly  in  a  line  wnth  the  vertebras,  and 
as  high  as  it  could  be  extended  above  the  head. 
By  this  expedient  I  succeeded  in  rolling  the  head  of 
the  humerus  downwards  and  inwards,  until  it  rested  on 
the  inferior  costa  of  the  scapula,  and  was  in  part  to 
be  felt  in  the  axilla.  Having  thus  reduced  it  as  far 
as  possible  into  the  situation  resembling  the  disloca- 
tion downwards,  I  brought  the  arm  and  fore  arm 
carefully  downwards  and  backwards  into  the  hori- 
zontal line,  keeping  the  head  of  the  humerus  in  the 
same  situation  all  the  time.  Extension  being  now 
made,  and  my  hand  being  firmly  placed  on  the  acro- 
mion, the  bone  was  easily  replaced.  The  rotatory 
motion  produced  considerable  pain  ;  and  just  as  the 
head  of  the  bone  crossed  the  edge  of  the  glenoid 
cavity,  severe  pain  was  felt,  and  a  noise  was  heard. 
My  father  and  Mr  Cantin  were  so  kind  as  to  assist 
me. 

Case,  —  September  24th,  1820,  —  Jenkins,  aged 
fourteen,  was  thrown  against  a  tree  by  a  furious 
horse,  by  which  accident  his  shoulder  was  displaced 


DISLOCATIONS   OP   THE  OS  HUMERI. 


407 


backwards.  The  tumour  produced  by  the  head  of 
the  bone  was  to  be  seen  in  a  line  with  the  spine  of 
the  scapula,  and  in  part  projecting  beyond  .it.  The 
acromion  projected  very  much,  and  the  integuments 
below  it  were  puckered  and  formed  a  cavity. 

Reduction,  —  I  rotated  the  arm  in  an  extended 
direction,  still  outwards,  and  raising  it  as  high  as  I 
could  I  brought  the  head  of  the  displaced  bone  to- 
wards the  axilla;  then  retaining  the  bone  in  this 
position,  having  carefully  brought  down  the  limb 
into  a  horizontal  line,  Mr  Cantin  and  I  made  an  ex- 
tension, and  the  limb  was  readily  reduced. 

I  am,  dear  Sir,  your's  respectfullv, 

C.    M.  COLEY. 


PARTIAL  DISLOCATION  OF  THE  OS  HUMERI. 

I  believe  this  is  not  a  very  rare  accident,  and  it 
shows  itself  by  the  following  marks. 

Symptoms,  —  The  head  of  the  bone  is  drawn  for- 
wards against  the  coracoid  process  ;  there  is  a  de- 
pression opposite  the  back  of  the  shoulder-joint,  and 
the  posterior  half  of  the  glenoid  cavity  is  percepti- 
ble, from  the  advance  of  the  head  of  the  bone  ;  the 
axis  of  the  arm  is  thrown  inwards  and  forwards  ;  the 
inferior  motions  of  the  limb  are  still  capable  of  being 
performed ;  but  its  elevation  is  prevented  by  the 
head  of  the  humerus  strikins:  a£:ainst  the  coracoid 
process  ;  there  is  an  evident  protuberance  formed 
by  the  head  of  the  bone  in  its  new  situation,  which 
is  felt  readily  to  roll  when  the  arm  is  rotated. 

Case.  —  Mr  Brown,  aged  fifty  years,  was  thrown 
from  his  chaise  on  his  shoulder,  and,  upon  examina- 
tion after  the  accident,  the  roundness  of  the  shoul- 
der was  lost,  and  there  was  a  hollow  under  the  aero- 


408  DISLOCATIONS  OF  THE  OS  HUMERI. 


mion-;  the  head  of  the  bone  projected  forwards  and 
inwards  against  the  coracoid  process;  the  arm  could 
be  raised  from  the  side  if  brought  forwards,  but- 
with  difficulty  raised  directly  upwards.  By  exten- 
sion of  the  shoulders  backwards,  1  at  last  brought 
the  head  of  the  bone  to  the  glenoid  cavity,  but  it 
directly  again  slipped  forwards  as  the  extension 
ceased.  This  dislocation  differs  from  that  forwards 
under  the  pectoral  muscle,  in  the  head  of  the  os 
humeri  being  still  on  the  scapular  side  of  the  cora- 
coid process,  while,  in  the  complete  dislocation  for- 
wards, it  is  thrown  on  its  sternal  side. 

Dissection.  —  The  only  case  of  dissection  of  this 
accident,  which  I  have  had  an  opportunity  of  seeing, 
was  the  following,  for  which  1  am  indebted  to  Mr 
Patey,  surgeon  in  Dorset-street,  who  had  the  subject 
brought  to  him  for  dissection,  at  the  anatomical 
room,  St  Thomas's  Hospital. 

Case,  —  Partial  dislocation  of  the  head  of  the  os 
humeri,  found  in  a  subject  brought  for  dissection  to 
St  Thomas's  Hospital^  during  the  latter  part  of  the 
year  1819. 

Jlppearanccs  before  dissection.  — The  appearances 
w^ere  as  follow  :  —  The  head  of  the  os  humeri, 
on  the  left  side,  was  placed  more  forward  than  is 
natural,  and  the  arm  could  be  drawn  no  farther 
from  the  side  than  the  half  way  to  the  horizontal 
position. 

Jlppearances  upon  dissection. — The  tendons  of  those 
muscles  which  are  connected  with  the  joint  were  not 
torn,  and  the  capsular  ligament  was  found  attached 
to  the  coracoid  process  of  the  scapula.  When  this 
ligament  was  opened,  it  was  found  that  the  head  of 
the  OS  humeri  was  situated  under  the  coracoid  pro- 
cess, which  formed  the  upper  part  of  the  new  gle- 
noid cavity;  the  head  of  the  bone  appeared  to  be 
thrown  upon  the  anterior  part  of  the  neck  of  the 


DISLOCATIONS   OF  THE   OS  HUMERI. 


409 


scapula,  which  was  hollowed,  and  formed  the  lower 
portion  of  the  glenoid  cavity.  The  natural  rounded 
form  of  the  head  of  the  bone  was  much  altered,  it 
having  become  irregularly  oviform,  with  its  long 
axis,  from  above  downwards;  a  small  portion  of  the 
original  glenoid  cavity  remained,  but  this  was  ren- 
dered irregular  on  its  surface  by  the  deposition  of 
cartilage  ;  there  were  also  many  particles  of  carti- 
laginous matter  upon  the  head  of  the  os  humeri,  and 
upon  the  hollow  of  the  new  cavity  in  the  cervix 
scapulae,  which  received  the  head  of  the  bone.  At 
the  upper  and  back  part  of  the  joint  there  was  a 
large  piece  of  the  cartilage,  which  hung  loosely 
into  the  cavity,  being  connected  with  the  synovial 
membrane,  at  the  upper  part  only,  by  two  or  three 
small  membranous  bands.  The  long  head  of  the 
biceps  muscle  seemed  lo  have  been  ruptured  near  to 
its  origin  at  the  upper  part  of  the  glenoid  cavity, 
for  at  this  part  the  tendon  was  very  small,  and  had 
the  appearance  of  being  a  new  formation.  (^See 
Plate,) 

James  Patey. 


Caw^e.  — This  accident  happens  from  the  same 
causes  which  produce  the  dislocation  forwards.  The 
anterior  part  of  the  ligament  is  torn,  and  the  head 
of  the  bone  has  an  opportunity  of  escaping  forwards 
to  the  coracoid  process. 

.  Means  of  reduction^  and  of  preventing  the  recurrence 
of  the  dislocation.  —  The  mode  for  its  l  eduction  will 
be  the  same  as  that  for  the  dislocation  forwards,  but 
it  is  necessary  to  draw  the  shoulders  backwards  to 
bring  the  head  of  the  bone  to  the  glenoid  cavity  ; 
and  immediately  when  the  reduction  is  completed, 
the  shoulders  should  be  bound  back  by  a  clavicle 
52  If 


410  DISLOCATIONS  OF  THE  OS  HUMERI. 


bandage,  or  the  bone  will  immediately  again  slip 
forward  against  the  coracoid  process. 

Dislocation  of  the  shoulder  complicated  with  frac- 
ture.—  Dislocations  of  the  shoulder  are  sometimes 
complicated  with  fracture  of  the  head  of  the  os 
humeri ;  and  we  have  a  preparation  in  the  Museum 
at  St  Thomas's  Hospital,  in  which  the  greater  tu- 
bercle at  the  head  of  the  bone  had  been  broken  off, 
and  the  os  humeri  thrown  into  the  axilla.  This 
complication  of  accident  does  not  add  to  the  diffi- 
culty of  reduction,  but  on  the  contrary,  rather 
facilitates  the  return  of  the  bone,  as  the  insertion  of 
the  principal  opponent  muscles,  the  supra  and  infra 
spinati,  is  removed  ;  but  it  increases  the  difficulty  of 
retaining  the  bone  within  the  glenoid  cavity  after 
the  reduction  is  completed. 


FRACTURE  OF  THE  NECK  OF  THE  OS  HUMERI,  WITH 
THE  DISLOCATION  FORWARDS,  UNDER  THE  PECTO- 
RAL MUSCLE. 

Case.  —  Mr  John  Blackburn  fell  from  his  horse, 
many  years  ago,  at  Enfield,  and  dislocated  his  shoul- 
der forwards.  Mr  Lucas,  sen..  Surgeon  of  Guy's 
Hospital,  was  sent  for,  who  said,  after  he  had  made 
considerable  extension,  that  the  bone  was  reduced. 
Five  weeks  afterwards  Mr  B.  came  to  London  and 
showed  me  his  shoulder,  when  the  appearances  of 
dislocation  still  remaining,  I  advised  a  further  ex- 
tension, to  which  he  would  not  consent.  I  had  fre- 
quent opportunities  of  seeing  him  afterwards,  but 
the  shoulder  exhibited  the  same  appearances  of 
dislocation.  He  had,  however,  the  power  of  using 
the  arm  and  hand  in  all  directions  excepting  up- 
wards, but  could  not  raise  his  arm  parallel  with  his 


DISLOCATIONS  OF  THE  OS  HUMERI. 


411 


body  ;  and  he  suffered  but  little  pain  or  inconve- 
nience. 

In  June,  1824,  he  died ;  and  as  he  had  always 
promised  me  the  dissection  of  his  shoulder  if  I  sur- 
vived him,  I  removed  it  in  the  presence  of  Mr  Ar- 
not,  Surgeon  of  Greenwich  Hospital,  examined  it 
with  great  care,  and  have  the  bones  preserved. 
The  deltoid  teres  major  and  coraco  brachialis  mus- 
cles did  riot  appear  to  me  to  be  altered  ;  the  supra- 
spinatus  was  lessened,  as  was  the  teres  minor,  which 
had  lost  considerably  of  its  natural  colour  :  the  in- 
fra-spinatus  was  stretched ;  the  subscapularis,  di- 
minished and  rounded  by  the  projection  of  the  head 
of  the  OS  humeri,  adhered  to  its  cartilaginous  sur- 
face. The  capsular  ligament  was  torn  under  the 
subscapularis  muscle,  but  every  other  part  was  en- 
tire. The  head  of  the  os  humeri  had  been  thrown 
forwards  on  the  inner  side  of  the  coracoid  process, 
and  had  been  united  by  bone  to  the  scapula  ;  but 
its  cartilage  remained  under  the  tendon  of  the  sub- 
scapularis. The  neck  of  the  os  humeri  was  broken 
through,  and  had  been  covered  by  a  granular  liga- 
mentous substance  ;  but  the  parts  were  kept  togeth- 
er only  by  the  ligament  of  the  joint,  and  a  new  and 
very  useful  joint  had  been  formed.  The  outer  edge 
of  the  glenoid  cavity  remained;  the  surface  of  the 
glenoid  cavity  was  granulated  and  ligamentous.  The 
greater  tubercle  of  the  os  humeri  was  exceedingly 
increased,  and  the  tendon  of  the  biceps  passed 
through  the  bone.  The  tubercles  were  separated 
with  the  body  of  the  bone,  and  not  with  its  head. 

This,  then,  was  a  case  of  fracture  of  the  cervix 
humeri  within  the  capsular  ligament,  terminating  in 
a  ligamentous  union. 


412  DISLOCATIONS  OF  THE  OS  HUMERI. 


COMPOUND  DISLOCATION   OF   THE   OS  HUMERI. 

An  injury  of  excessive  violence  will  sometimes 
occasion  the  head  of  the  bone  to  be  forced  through 
the  integuments  in  the  dislocation  forwards.  It  hap- 
pened in  the  practice  of  Mr  Saumarez,  and  Mr 
Dixon,  of  Newington;  and  for  the  following  detail 
of  its  circumstances  I  am  indebted  to  Mr  Dixon. 

Mr  D'ixon^s  case.  —  My  dear  Sir  :  —  1  feel  plea- 
sure in  answering  the  queries  you  have  put.  The 
accident  happened  to  Robert  Price,  fifty-five  years 
of  age,  who,  on  returning  in  a  state  of  intoxication 
from  the  Borough,  fell  down  upon  his  shoulder. 
Upon  examination,  I  found  that  the  head  of  the  bone 
having  passed  through  the  integuments  in  the  axilla, 
lay  exposed  upon  the  anterior  part  of  the  chest,  and 
situated  over  the  pectoral  muscle  on  the  right  side. 
The  reduciioii  of  the  dislocation  was  easy,  being 
perfoi  med  without  the  necessity  of  raising  him  from 
the  state  of  stupor  and  insensibility  in  which  he  was 
lying,  by  the  usual  method  of  extension  and  counter- 
extension,  taking  care  only  to  guide  the  bone  into 
the  glenoid  cavity;  he  was  then  put  to  bed  and  an 
evaporating  lotion  applied.  On  the  following  morn- 
ing considerable  pain  and  tension  had  come  on  ;  he 
was  bled,  and  purged  freely;  a  large  poultice  was 
applied  over  the  joint,  and  anodynes  were  given  to 
lessen  the  pain  and  procure  sleep;  leeches  were 
frequently  applied  in  the  neighbourhood  of  the  joint 
for  the  first  ten  days  or  fortnight,  after  which,  a 
copious  discharge  of  pus  issued  from  the  wound  in 
the  axilla.  The  constitution  now  felt  the  effects  of 
so  important  an  injury  ;  he  became  irritable,  restless, 
and  lost  flesh.  Healthy  pus  was  discharged  freely 
from  the  joint  for  ten  or  twelve  weeks,  when  it 
somewhat  abated.    A  succession  of  small  abscesses, 


DISLOCATIONS   OF  THE  OS  HUMERI.  413 


situated  in  the  cellular  meaibrane,  surrounding  the 
joint,  were  exceedingly  troublesome  for  several 
months:  some  of  them  formed  extensive  sinuses,  re- 
quiring to  be  freely  dilated.  The  discharge  of  pus 
from  the  joint  was  kept  up  nearly  twelve  months, 
when  it  finally  ceased,  leaving  the  joint  anchylosed, 
and  the  wound  closed.  He  was  quite  recovered 
fourteen  months  after  the  accident,  when  he  called 
on  me,  and  felt  gratified,  by  showing  how  freely  he 
could  make  use  of  the  fore  arm,  and  handle  his  pen 
for  all  the  purposes  of  business.  He  is  still  living  in 
Paradise-row,  Stockwell,  and  is  employed  by  the 
parish  of  Lambeth  as  a  collector  of  assessed  taxes. 

I  am,  my  dear  Sir, 
Your's  faithfully, 

P.  Dixon, 

Treatment.  —  Such  a  case  will  require  an  imme- 
diate reduction,  by  the  means  which  I  have  describ- 
ed for  the  dislocation  of  the  os  humeri  forwards; 
and,  in  general,  the  greater  the  violence  done  to  the 
injured  limb,  the  more  easy  is  the  reduction,  from 
the  diminution  of  the  constitutional  powers  which  so 
great  a  shock  produces.  When  the  bone  is  replac- 
ed, lint,  dipped  in  blood,  is  to  be  applied  to  the 
wound;  or,  if  the  wound  be  large,  a  suture  should 
be  employed,  and  then  the  lint  applied  :  adhesive 
plaster  should  be  used  to  support  approximation, 
and  the  limb  should  be  kept  close  to  the  side  by 
means  of  a  roller  passed  round  the  body,  including 
the  arm,  and  thus  preventing  the  least  motion  of  the 
head  of  the  bone  :  by  these  means  the  suppurative 
inflammation  may  be  prevented,  and  the  cure  may 


414  DISLOCATIONS  OF  THE  OS  HUMERI. 


proceed  without  protracted  suffering,  or  any  danger 
to  the  patient's  life."^ 

*  In  reducing  a  dislocation  of  two  months  standing  at  the 
Philadelphia  Alms-Hoiise,  professor  Gibson  states  that  a  rupture 
of  the  axillary  artery  was  occasioned,  which  was  speedily  fol- 
lowed hy  the  death  of  the  patient.  The  dissection  of  this  case 
is  taken  from  the  7th  volume  of  the  Philadelphia  Journal,  p. 
84. 

^Dissection.  —  Three  incisions  were  made  —  one  from  the 
acromion  process,  along  the  course  of  the  clavicle,  as  far  as  the 
sternum  —  another  perpendicular  to  the  sternum,  and  about  ten 
inches  long —  a  third  nearly  at  right  angles  with  the  lower  ex- 
tremity of  the  perpendicular  one,  and  running  across  the  chest 
towards  the  arm-pit.  The  integuments  and  pectoral  muscles 
being  elevated  along  the  edge  of  the  sternum,  and  thrown  back- 
wards towards  the  shoulder,  a  considerable  quantity  of  coagu- 
lated blood  was  found,  filling  the  cellular  membrane,  and  lying 
in  masses  between  the  interstices  of  the  muscles.  In  order  to 
ascertain  the  condition  of  the  large  vessels  beneath  the  clavicle, 
this  bone  was  separated  at  its  juncture  with  the  sternum,  and 
raised.  The  course  of  the  subclavian  artery  and  vein  was  then 
distinctly  seen.  A  small  opening  was  made  in  the  vein,  into 
which  a  bougie  was  introduced  for  several  inches,  towards  the 
axilla,  as  a  guide  during  the  dissection ;  but  the  vessel  was  found 
perfectly  sound  throughout.  Under  the  vein,  as  it  passes  near 
the  glenoid  cavity,  a  large  mass  of  coagulated  blood  was  ob- 
served, and  upon  clearing  this  away,  the  axillary  artery  was 
seen  protruding,  with  its  mouth  open,  having  been  torn  directly 
across  and  separated  from  its  connexions.  Upon  further  examin- 
ation, it  was  discovered  that  the  head  of  the  bone,  at  the  time 
of  the  luxation,  had  been  carried  downwards  into  the  axilla, 
about  an  inch  and  a  half  below  the  glenoid  cavit}',  where  it 
formed  a  white  ligamentous  cup-like  socket,  in  the  subscapulary 
muscle,  and  pressing  upon  the  axillary  artery,  produced  such 
a  degree  of  inflammation  as  gave  rise  to  a  copious  effusion  of 
coagulable  lymph,  which  united  the  artery  completely,  for  some 
distance,  to  the  capsule  of  the  joint,  where  it  surrounded  the 
neck  of  the  bone.  The  lower  part  of  the  capsule  was  lorn  and 
separated  from  the  neck  of  the  humerus ;  the  upper  part  re- 
mained entire,  and  was  very  much  thickened.  The  head  of  the 
bone  filled  completely  the  old  socket  or  glenoid  cavity.  Be- 


DISLOCATIONS   OP  THE  OS  HUMERI.  415 


PARTIAL    DISLOCATION    OF  THE  OS  HUMERI  FORWARDS. 

Mr  Bachelor,  of  Southville,  aged  thirty-six,  fell 
from  a  chaise  on  the  12th  of  November,  and,  as  he 
supposes,  pitched  on  his  shoulder.  On  rising  he 
could  not  move  his  right  arm  for  ten  minutes,  when 
some  sudden  spasm  gave  him  the  power  of  moving 
it  underhand.  Inflammation  succeeded;  the  shoul- 
der became  much  swollen,  with  pain  down  the  arm 
to  the  fingers,  and  particularly  in  the  direction  of  the 
cubital  nerve.  On  looking  at  the  arm  the  same 
evening,  he  found  that  the  os  humeri  appeared  to  be 
advanced. 

It  is  two  months  since  the  injury,  and  the  hand  is 
now  benumbed.  There  is  much  pain  at  the  inser- 
tion of  the  biceps  into  the  fore  arm,  so  that  he  has 
been  often  obliged  to  rise  twice  duririg  the  night  to 
put  his  hand  in  warm  water. 

The  appearances  are,  a  projection  of  the  acro- 
mion, and  a  hollow  beneath  it;  the  head  of  the  os 
humeri  rests  against  and  under  the  coracoid  process, 
and  the  scapular  end  of  the  clavicle  is  opposite  to 
the  middle  of  the  head  of  the  bone.  The  biceps 
muscle  was  relaxed  and  lessened  ;  the  coracoid  pro- 
cess of  the  scapula  was  with  difficulty  felt  above, 
and  to  the  inner  side  of  the  head  of  the  os  humeri. 

neath  the  deltoid  muscle  there  was  a  large  hollow  filled  with 
blood,  and  the  whole  arm,  as  far  as  the  elbow,  had  been  exten- 
sively injected  with  the  same  fluid.  The  os  humeri  was  care- 
fully dissected  from  the  condyles  to  its  head,  and  the  periosteum 
entirely  scraped  off,  without  showing  the  slightest  vestige  of  a 
fracture.  The  long  tendon  of  the  biceps  was  found  considerably 
elongated,  but  not  ruptured.' 

For  the  whole  of  the  interesting  description  of  Dr  Gibson,  the 
reader  is  referred  to  the  same  volume,  p.  80.  J.  D,  G 


416  DISLOCATIONS   OF  THE  OS  HUMERI. 


The  principle  of  treatment  in  these  cases  is,  to 
oppose  the  pectoralis  major  by  a  clavicle-bandage, 
with  a  broad  strap  over  the  head  of  the  os  humeri, 
and  by  bi'inging  the  elbow  forward  to  keep  the  head 
of  the  OS  humeri  back. 


DISLOCATION  OF  THE  OS  HUMERI  BACKWARDS. 

^  A  man  fell  from  the  roof  of  a  coach,  and  struck 
the  point  of  his  left  shoulder  against  a  projecting 
stone.  He  suffered  little  pain  from  the  accident ; 
but  finding  himself  incapable  of  using  his  arm,  he 
came  immediately  to  the  hospital. 

Upon  examination,  I  found  that  the  head  of  the 
humerus  was  thrown  upon  the  dorsum  of  the  scapu- 
la, where  it  presented  a  considerable  prominence, 
behind  the  glenoid  cavity,  and  immediately  under 
the  spine  of  that  bone.  The  vacancy  beneath  the 
acromion  was  not  so  remarkable  as  in  the  axillary 
dislocation.  The  arm  was  closely  applied  to  the  side, 
and  slightly  inverted,  the  elbow  being  directed  ra- 
ther anteriorly.  Free  motion  was  practicable  for- 
ward and  backward,  but  the  limb  could  not  be  raised 
or  carried  across  the  breast  without  great  difficulty. 

Reduction  was  easily  effected  in  the  following 
manner:  —  The  scapula  being  fixed,  extension  was 
made,  by  means  of  a  cloth  twisted  around  the  elbow, 
for  about  three  minutes,  when  finding  no  disposition 
in  the  head  of  the  bone  to  return  to  the  cavity,  al- 
though it  was  already  in  close  contact  with  its  lower 
and  back  mara^ln,  I  made  a  fulcrum  of  my  right 
hand  in  the  axilla,  and  grasping  the  elbow  in  my  left, 
readily  succeeded  in  lifting  it  into  its  socket. 

J.  S.  Perry. 

Bartholomew's  Hospital 


DISLOCATIONS   OF  THE  OS  HUMERI.  417 

Mr  Perry  had  the  kindness  to  send  me  the  fore- 
fi^oing  case,  for  which  I  am  much  indebted  to  him. 
Our  large  hospitals  in  London  should  be  made  as 
conducive  as  possible  to  the  advantage  of  the  public,, 
by  a  liberal  and  reciprocal  communication. 


53 


-FRACTURES  NEAR  THE  SHOULDER- 
JOINT,  LIABLE  TO  BE  MISTAKEN 
FOR  DISLOCATIONS. 


FRACTURE  OF  THE  ACROMION. 

Diagnostic  symptoms,  —  This  point  of  bone  is 
sometimes  broken,  in  which  case,  when  the  shoulders 
are  compared,  the  roundness  of  the  injured  side  is 
lost,  and  part  of  the  attachment  of  the  deltoid  mus- 
cle being  broken  off,  the  head  of  the  os  humeri  sinks 
towards  the  axilla  as  far  as  the  capsular^  ligament 
will  permit.  On  tracing  the  acromion^^from  the 
spine  of  the  scapula  to  the  clavicle,  just  at  their 
junction,  a  depression  is  felt,  from  the  fall  of  the 
fractured  portion.  If  the  distance  be  measured  from 
the  sternal  end  of  the  clavicle  to  the  extremity  of 
the  shoulder,  it  will  be  found  lessened  on  the  injured 
side.  If  the  surgeon  raises  the  arm  from  the  elbow, 
so  as  to  put  the  deltoid  muscle  in  motion,  the  natural 
form  of  the  shoulder  is  directly  restored,  but  the 
deformity  returns  immediately  when  the  arm  is  again 
suffered  to  fall. 


FRACTURES  OF  THE  SHOULDER-JOINT.  419 


This  accident  is  best  detected  and  distinguished 
from  dislocation  by  raising  the  arm  at  the  elbow  : 
having  restored  the  figure  of  the  part,  the  surgeon 
places  his  hand  upon  the  acromion  and  rotates  the 
arm,  when  a  crepitus  can  be  distinctly  perceived  at 
the  point  of  the  shoulder,  and  along  the  superior 
portion  of  the  spine  of  the  scapula.  The  patient,  as 
soon  as  the  accident  has  happened,  feels  as  if  his  arm 
were  falling  off,  the  shoulder  dropping  with  a  great 
sense  of  weight,  and  there  being  but  little  power  to 
raise  the  limb. 

Treatment, — Fracture  of  the  acromion  scapulas 
will  unite  by  bone,  but  it  generally  unites  by 
ligamentous  substance,  in  consequence  of  the  diffi- 
culty which  exists  in  producing  adaptation,  and  in  pre- 
serving the  limb  perfectly  at  rest  during  the  period 
required  for  union.  In  the  treatment  of  this  accident, 
the  head  of  the  os  humeri  is  the  splint  which  is  em- 
ployed to  keep  the  acromion  in  its  natural  situation ; 
and  with  this  view  the  elbow  is  raised  and  the  arm 
is  fixed ;  thus  the  bone  will  be  elevated  to  the  infe- 
rior surface  of  the  acromion,  and  if  it  be  kept  stead- 
ily in  that  position,  it  will  support  and  keep  in  its 
place  the  broken  process.  The  deltoid  muscle 
should  be  also  relaxed,  and  this  is  best  effected  by  a 
cushion  placed  between  the  elbow  and  the  side  ;  for 
if  the  elbow  be  brought  close  to  the  side,  the  broken 
acromion  is  further  separated-  The  arm  should  be 
raised  as  much  as  is  possible,  and  the  elbow  be  carri- 
ed a  little  backwards,  and  then  bound  to  the  chest 
by  a  roller;  in  this  position  it  should  be  kept  firmly 
fixed  for  three  weeks,  every  thing  being  done  to 
prevent  any  motion  of  the  bone.  Very  little  inflam- 
mation succeeds  this  accident,  and  the  disposition  to 
ossific  union  is  very  feeble  in  the  separated  portions 
of  bone. 

If  a  pad  be  placed  in  the  axilla,  the  broken  portion 


420  FRACTURES  NEAR  THE  SHOULDER-JOINT. 


becomes  widely  separated  from  the  spine  of  the 
scapula  because  it  throws  out  the  head  of  the  os 
humeri. 


^         FRACTURE  OF  THE  NECK  OF  THE  SCAPULA. 

Symptoms.  —  But  the  accident  which  is  much  more 
liable  to  be  mistaken  for  dislocation,  is  the  frac- 
ture through  the  narrow  part  of  tlie  cervix  scapulas, 
immediately  opposite  the  notch  of  the  superior  costa ; 
by  which  the  glenoid  cavity  becomes  detached  from 
the  scapula,  and  the  head  of  the  bone  falls  with  it 
into  the  axilla ;  the  shoulder  in  this  case  falls  ;  there 
is  a  hollow  below  the  acromion  from  the  sinking  of 
the  deltoid  muscle,  and  the  head  of  the  os  humeri 
can  be  felt  in  the  axilla. 

Case.  —  A  young  lady  was  thrown  from  a  gig,  by 
the  fall  of  the  horse,  in  the  Strand;  and  being  car- 
ried to  her  house,  a  surgeon  in  the  neighbourhood 
was  sent  for,  who  told  her  the  shoulder  was  dislo- 
cated ;  by  extension  all  the  appearances  of  dis- 
location were  removed,  and  he  bound  up  the  arm. 
On  the  following  morning  he  requested  me  to  see 
the  case,  as  the  arm,  he  said,  was  again  dislocated. 
On  examination  I  found  the  head  of  the  bone  in  the 
axilla,  and  the  shoulder  so  fallen  and  flattened,  as  to 
give  to  the  accident  many  of  the  characters  of  dis- 
location ;  however,  by  elevating  the  shoulder,  in 
raising  the  arm  at  the  elbow,  and  the  head  of  the 
bone  from  the  axilla,  it  was  immediately  replaced  ; 
but  when  I  gave  up  this  support  the  limb  instantly 
sunk  again.  I  then  rotated  the  elbow,  and  pressing 
the  coracoid  process  of  the  scapula  with  my  fingers, 
by  grasping  the  top  of  the  shoulder,  directly  felt  a 
crepitus.  Having  satisfactorily  ascertained  the  nature 


FRACTURES  NEAR  THE  SHOULDER-JOINT.  421 


of  the  accident,  I  placed  a  thick  cushion  in  the  axilla, 
and  drawing  the  shoulder  into  its  natural  position, 
secured  it  by  the  application  of  a  clavicle  bandage, 
and  in  seven  weeks  it  became  united  without  defor- 
mity. 

The  degree  of  deformity  produced  by  this  acci- 
dent depends  upon  the  extent  of  laceration  of  a  liga- 
ment which  passes  from  the  under  part  of  the  spine 
of  the  scapula  to  the  glenoid  cavity,  and  which  is  not 
generally  described  in  anatomical  books.  If  this  be 
torn,  the  glenoid  cavity  and  the  head  of  the  os  hu- 
meri fall  deeply  into  the  axilla ;  but  the  displacement 
is  much  less  if  this  remain  whole. 

Diagnostic  marks. —  The  diagnostic  marks  of  this 
accident  are  three  :  the  facility  with  which  the 

parts  are  replaced  ;  secondly^  the  immediate  fall  of 
the  head  of  the  bone  into  the  axilla,  when  the  ex- 
tension is  removed  ;  and  thirdly^  the  crepitus  which 
is  felt  at  the  extremity  of  the  coracoid  process  of  the 
scapula,  when  the  arm  is  rotated.  The  best  method 
of  discovering  the  crepitus  is,  for  the  surgeon's  hand 
to  be  placed  over  the  top  of  the  shoulder,  and  the 
point  of  the  fore  finger  to  be  rested  on  the  coracoid 
process  ;  the  arm  being  then  rotated,  the  crepitus  is 
directly  perceived,  because  the  coracoid  process 
being  attached  to  the  glenoid  cavity,  and  being  broken 
offAvith  it,  although  itself  uninjured,  the  crepitus  is 
communicated  through  the  medium  of  that  process. 

Treatment  of  this  accident.  —  The  treatment  of 
this  fracture  consists  in  attention  to  two  principles. 
The  first  is  to  carry  the  head  of  the  os  humeri  out- 
wards;  and  the  second,  to  raise  the  glenoid  cavity 
and  arm.  The  former  is  effected  by  a  thick  cushion 
placed  in  the  axilla,  which  presses  the  head  of  the 
bone  and  glenoid  cavity  outwards,  and  this  may  be 
confined  by  the  clavicle  bandage  ;  the  latter  is  pro- 
duced by  placing  the  arm  in  a  short  sling,  and  then 


422 


FRACTURES  NEAR  THE  SHOULDER-JOINT. 


the  raised  head  of  the  os  humeri  supports  the  gle- 
noid cavitj  and  cervix  scapulae,  and  keeps  it  steadily 
in  its  place  until  union  is  produced.  The  time  re- 
quired for  recovery  from  these  accidents  in  the  adult 
is,  from  ten  to  twelve  weeks;  in  the  very  young,  all 
the  motions  of  the  limb  are  restored  in  a  shorter 
period,  but  it  is  a  long  time  before  the  limb  recovers 
its  strength. 


FRACTURE  OF  THE  NECK  OF  THE  OS  HUMERI. 

*^ge  ;  symptoms, —  The  humerus  is  sometimes 
broken  just  below  its  tubercles,  through  its  cervix. 
I  have  seen  this  accident  happen  both  in  old  and  in 
young  persons,  but  it  rarely  occurs  in  middle  age. 
In  the  young  it  happens  at  the  junction  of  the  epi- 
physis, where  the  cartilage  is  situated  ;  and  in  the  old 
it  arises  from  the  greater  softness  of  this  part  of  the 
bone.  In  this  fracture  the  head  of  the  bone  remains 
in  its  place,  but  the  body  of  the  humerus  sinks  into 
the  axilla,  where  its  extremity  can  be  felt ;  and  it 
draws  down  the  deltoid  muscle,  so  as  to  lessen  the 
roundness  of  the  shoulder.  Just  as  I  was  writing 
this  account,  a  child  was  brought  into  Guy's  Hospital 
with  tiiis  accident,  on  which  I  made  the  following 
notes. 

Its  age  was  ten  years.  The  symptoms  of  the  in- 
jury were  inability  of  moving  the  elbow  from  the 
side,  or  of  supporting  the  arm,  unless  by  the  aid  of 
the  other  hand,  without  great  |)aln.  The  tension 
which  succeeded  filled  up  the  hollow  which  was  at 
first  produced  by  the  fall  of  the  deltoid  muscle. 
When  the  head  of  the  bone  was  fixed,  the  fractured 
extremity  of  the  body  of  the  humerus  could  be  tilt- 
ed under  the  deltoid  muscle,  so  as  to  be  felt,  and 


FRACTURES  NEAR  THE  SHOULDER-JOINT.  423 


even  shown,  by  raising  the  arm  at  the  elbow.  Cre- 
pitus could  be  perceived,  not  by  rotating  the  arm, 
but  by  raising  the  bone  and  pushing  it  outwards. 
The  cause  of  the  fracture  was  a  fall  upon  the  shoul- 
der into  a  saw-pit  of  the  depth  of  eight  feet. 

It  is  in  old  persons  that  this  accident  is  most  liable 
to  be  mistaken  for  dislocation;  for  in  them  the  flex- 
ibility of  the  joint  is  much  diminished  by  it,  and  the 
changes  of  position  of  the  bone  are  less  easily  pro- 
duced. 

Diagnostic  symptoms.  —  The  best  diagnostic  marks 
are  the  following.  Embrace  the  head  of  the  os 
humeri  with  the  fingers  and  fix  it,  then  rotate  the 
arm  at  the  elbow,  and  it  will  be  found  that  the  head 
of  the  bone  does  not  obey  the  rotatory  motion,  as  it 
is  separated  from  the  body  of  the  humerus  by  the 
fracture,  which  is,  in  this  case,  external  to  the  cap- 
sular ligament.  The  reduced  bone  in  these  instances 
unites  in  from  three  to  six  weeks,  according  to  the 
age  of  the  patient. 

Treatment,  —  The  treatment  consists  in  applying 
a  roller  from  the  elbow  to  the  shoulder-joint,  in 
placing  a  splint  on  the  inner  and  on  the  outer  side  of 
the  arm,  and  in  confining  these  by  means  of  a  roller. 
A  cushion  is  theo  to  be  placed  in  the  axilla,  to  throw 
out  the  head  of  the  bone,  and  the  arm  is  to  be  genlly 
supported  by  a  sling;  for  if  it  be  much  raised,  the 
bones  will  overlap,  and  the  union  will  be  deformed* 

Case,  —  William  Mills,  aged  seventy-two,  during 
the  severe  frost  in  1823,  fell  down  upon  his  shoulder, 
three  days  after  which  he  was  admitted  into  Guy's 
Hospital.  The  arm  and  shoulder  were  much  swol- 
len, there  was  also  acute  pain  and  discoloration  of 
of  the  integuments.  Crepitus  could  not  be  felt ;  and, 
from  the  degree  of  swelling,  it  was  impossible  to  as- 
certain the  precise  nature  of  the  accident.  Leeches 
and  evaporating  lotions  were  applied.  The  shoulder 
was  again  examined  on  the  second  day,  after  the 


424        FRACTURES  NEAR  THE  SHOULDER-JOINT. 


swelling  had  somewhat  subsided,  and  a  fracture  of 
the  neck  of  the  humerus  was  discovered.  The  pain 
and  swelling  again  became  greater,  and  gradually 
increased;  the  integuments  inflamed,  having  the  ap- 
pearance of  erysipelas;  the  skin  became  discolored 
and  gangrenous.  He  was  feverish  and  irritable, 
then  delirious,  and  gradually  sunk  on  the  tenth  day 
from  the  accident. 

Appearances  on  dissection,  —  The  integuments  and 
cellular  membrane,  on  the  inner  part  of  the  shoulder 
over  the  clavicle,  were  considerably  thickened,  hav- 
ing a  sloughy  appearance  ;  and  on  cutting  through 
the  deltoid  muscle,  a  large  quantity  of  bloody  matter, 
mixed  with  serum,  was  effused.  The  capsular  liga- 
ment was  extensively  lacerated;  the  humerus  was 
fractured  through  the  cervix,  also  obliquely  through 
the  head ;  and  a  small  spicula  of  bone  was  separated 
from  the  cervix. 

James  Mash, 

Jan,  1823.  Dresser  to  Mr  Forster. 


STRUCTURE  OF    THE  ELBOW-JOINT» 


jBone^.—  Tms  joint  is  composed  of  three  bones — - 
the  lower  extremity  of  the  humerus,  the  upper  part 
of  the  uhia,  and  the  head  of  the  radius.  The  ex- 
tremity of  the  OS  humeri  is  expanded,  and  presents 
two  lateral  eminences,  which  are  called  its  condyles, 
the  internal  of  which  is  the  most  prominent ;  be- 
tween these  condyles  the  articular  surface  for  the 
ulna  is  situated,  which  is  in  the  form  of  a  pulley ; 
and  above  it,  both  anteriorly  and  posteriorly,  is  situ- 
ated a  deep  cavity,  with  a  thin  partition  intervening. 
On  the  lower  extremity  of  the  external  condyle  is 
placed  an  articular  surface,  on  which  the  head  of 
the  radius  is  received.  The  upper  extremity  of 
the  ulna  forms  two  processes,  with  an  articulatory 
surface  between  them,  which  is  adapted  to  the  pul- 
ley-like articular  surface  of  the  os  humeri  :  both 
these  surfaces  of  the  ulna  and  humerus  are  covered 
with  cartilage.  The  superior  and  posterior  process 
of  the  ulna  is  called  the  olecranon,  which  forms  the 
point  of  the  elbow,  and  into  which  the  triceps  mus- 
54 


426 


STRUCTURE  OF  THE  ELBOW-JOINT. 


cle  is  inserted.  The  anterior  and  smaller  process 
is  called  the  coronoid,  which  gives  insertion  to  the 
brachialis  internus.  When  the  arm  is  extended,  the 
point  of  the  olecranon  is  received  into  the  posterior 
cavity,  between  the  condyles  of  the  humerus  ;  and 
when  it  is  flexed,  the  coronoid  process  passes  into 
the  anterior  hollow ;  so  that  these  cavities  are 
formed  for  the  purpose  of  allowing  free  extension 
and  flexion  of  the  arm.  The  head  of  the  radius  is 
rounded,  and  rests  upon  the  broad  articular  surface 
of  the  humerus,  upon  which  it  bends  ;  on  its  inner 
side  it  is  received  into  an  articular  cavity  on  the  ra- 
dial side  of  the  coronoid  process  of  the  ulna,  upon 
which  the  radius  rolls ;  and  thus  all  the  motions  of 
the  fore  arm  are  performed.  Immediately  below 
its  head  the  radius  becomes  smaller,  and  this  part  is 
called  its  cervix  :  at  the  distance  of  an  inch  below 
its  head  is  seated  a  process  which  is  called  its  tu- 
bercle. 

Ligaments;  capsular,  —  The  ligaments  which  bind 
these  bones  together  are  the  capsular,  Avhich  is 
united  with  the  condyles,  and  with  the  portion  of 
bone  above  the  cavities  of  the  os  humeri ;  it  passes 
over  the  extremity  of  the  humerus,  and  is  united 
behind  to  the  olecranon,  and  to  the  coronoid  process, 
on  the  fore  part  of  the  ulna :  it  is  also  connected  to 
the  coronary  ligament  of  the  radius.  This  ligament 
posteriorly  is  loose  and  slender,  but  on  the  fore  part 
it  is  of  considerable  strength. 

Coronary.  —  The  coronary  ligament  surrounds  the 
head  of  this  radius  :  it  is  connected  above  with  the 
capsular  ligament,  and  below  with  the  neck  of  the 
radius,  by  a  thin  ligament  of  sufficient  length  to 
allow  of  rotation  of  the  head  of  the  bone  :  it  is 
also  attached  to  the  fore  and  back  part  of  the 
coronoid  process  of  the  ulna,  at  its  lateral  articu- 
latory  surface,  and  thus  firmly  unites  the  radius 


STRUCTURE  OF  THE  ELBOW-JOINT. 


427 


with  the  ulna,  yet  allows  of  the  rotation  of  the 
former. 

Brachio  cubital.  —  There  are  four  peculiar  liga- 
ments:—  First,  the  brachio  cubital,  or  internal  lat- 
eral ligament,  which  passes  from  the  internal  con- 
dyle of  the  OS  humeri  into  the  coronoid  process  of 
the  ulna. 

Brachio  radial  —  Secondly,  the  brachio  radial,  or 
external  lateral  ligament,  which  is  fixed  to  the  ex- 
ternal condyle  of  the  humerus,  and  to  the  coronary 
ligament  of  the  radius  ;  these  ligaments  give  to  the 
joint  a  strong  lateral  support. 

Oblique.  —  The  third  llganlent  is  the  oblique, 
which  passes  from  the  coronoid  process  of  the  ulna 
to  the  radius,  just  below  its  tubercle  ;  and  it  is  this 
ligament  which  limits  the  rotation  of  the  radius. 

A  ligament  also  reaches  from  the  inner  side  of 
the  coronoid  process  to  the  olecranon  ;  and  when 
this  latter  process  is  broken  off*,  it  is  this  ligament, 
in  some  instances,  which  prevents  its  extensive  sep- 
aration. 

Muscles.  —  The  muscles  of  the  joint  are,  first, 
the  brachialis  internus,  which  passes  over  the  an- 
terior part  of  the  condyles  and  capsular  ligament  to 
which  it  is  attached  :  it  is  inserted,  in  an  oblique  di- 
rection, into  the  coronoid  process,  and  into  the  body 
of  the  ulna  just  below  it.  The  use  of  this  muscle 
is  to  bend  the  fore  arm,  and  give  support  to  the  el- 
bow-joint, by  strengthening  the  capsular  ligament. 
The  next  muscle  is  the  triceps,  which  arises  by  one 
of  its  heads  from  the  inferior  costa  of  the  scapula, 
and  by  its  two  others  from  the  os  humeri :  it  de- 
scends to  the  capsular  ligament,  to  the  loose  portion 
of  which  it  adheres,  and  is  inserted  into  the  point 
of  the  olecranon.  This  muscle  extends  the  arm, 
and  draws  up  and  supports  the  capsular  ligament. 
Thirdly,  the  anconeus,  which  arises  from  the  back 


428 


STRUCTURE  OF  THE  ELBOW-JOINT. 


part  of  the  external  condyle  of  the  humerus,  ad- 
heres to  the  capsular  ligament,  and  is  inserted  to  the 
extent  of  an  inch  and  a  half  into  the  body  of  the 
ulna,  directly  below  the  olecranon.  The  course  of 
this  muscle  is  oblique ;  and  whilst  it  extends  the 
arm,  it  supports  the  capsular  ligament.  The  biceps 
muscle  does  not  protect  the  ulna  joint,  but  has  great 
influence  in  preventing  a  dislocation  of  the  radius 
forwards,  in  the  extended  state  of  the  arm.  It  is 
not  connected  with  the  capsular  ligament,  as  the 
other  muscles  are  ;  but  arising  from  the  glenoid  cav- 
ity, and  coracoid  process  of  the  scapula,  tendinous, 
it  becomes  fleshy  in  its  middle,  and  again  forms  a 
tendon  at  the  elbow-joint,  which  is  fixed  into  the 
tubercle  of  the  radius.  This  muscle  bends  the  fore 
arm,  rotates  the  radius  outwards,  that  is,  supines 
the  hand,  and  compresses  the  capsular  ligament  op- 
posite the  head  of  the  radius. 


DISLOCATIONS  OF  THE  ELBOWJOINT. 


There  are  five  species  of  dislocation  of  this  joint :  — 
First,  both  bones  are  dislocated  backwards. 
Secondly,  both  are  dislocated  laterally. 
Thirdly,  the  ulna  is  dislocated  separately  from  the 

radius. 

Fourthly,  the  radius  alone  is  dislocated  forwards:  and 
Fifthly,  the  radius  is  dislocated  backwards* 


DISLOCATION   OF  BOTH  BONES  BACKWARDS. 

Symptoms.  —  This  dislocation  is  strongly  marked 
by  the  great  change  which  is  produced  in  the  form 
of  the  joint,  and  by  its  partial  loss  of  motion.  The 
shape  of  the  elbow  is  altered,  as  there  is  consider- 
able projection  posteriorly,  formed  by  the  ulna  and 
radius,  above  the  natural  situation  of  the  olecranon. 
On  each  side  of  the  olecranon  appears  a  hollow.  A 
considerable  hard  swelling  is  felt  at  the  fore  part  of 
the  joint,  immediately  behind  the  tendon  of  the 
biceps  muscle,  formed  by  the  extremity  of  the  hu- 


430  DISLOCATIONS   OP  THE  ELBOW-JOINT. 


merus ;  the  hand  and  fore  arm  are  supine,  and  can- 
not be  rendered  entirely  prone.  The  flexion  of  the 
joint  is  also  in  a  great  degree  lost. 

Dissection  of  this  Dislocation. 

Dissection  of  the  dislocation  backwards,  —  1  have 
had  an  opportunity  of  dissecting  a  compound  disloca- 
tion of  this  joint,  where  the  radius  and  ulna  were 
thrown  backwards,  and  it  is  preserved  in  the  Museum 
at  St  Thomas's  Hospital  [see  Plate^,  The  coronoid 
process  of  the  ulna  was  thrown  into  the  posterior 
fossa  of  the  os  humeri,  and  the  olecranon  projected 
at  the  back  part  of  the  elbow^,  above  its- usual  situa- 
tion, an  inch  and  a  half;  the  radius  was  placed  be- 
hind the  external  condyle  of  the  os  humeri,  and  the 
humerus  was  thrown  forwards  on  the  anterior  part 
of  the  fore  arm,  where  it  formed  a  large  projection. 
The  capsular  ligament  was  torn  through,  anteriorly, 
to  a  great  extent.  The  coronary  ligament  remained 
entire.  The  biceps  muscle  was  slightly  put  upon 
the  stretch,  by  the  radius  receding;  but  the  brachi- 
alis  internus  was  excessively  stretched  by  the  altered 
position  of  the  coronoid  process  of  the  ulna.  (See 
Plate,) 

Cause  of  the  accident,  —  This  accident  usually 
happens  in  a  fall  when  a  person  puts  out  his  hand  to 
save  himself,  the  arm  not  being  perfectly  extended, 
so  that  the  bones  are  forced  back  behind  the  axis  of 
the  OS  humeri,  by  pressure  of  the  whole  weight  of 
the  body  upon  them. 

This  dislocation  is  easily  reduced  by  the  following 
means.  The  patient  is  made  to  sit  down  upon  a 
chair,  and  the  surgeon,  placing  his  knee  on  the  inner 
side  of  the  elbow-joint,  in  the  bend  of  the  arm,  and 
taking  hold  of  the  patient's  wrist,  bends  the  arm;  at 


Dislocations  of  the  elbow- joint. 


431 


the  same  time  he  presses  on  the  radius  and  ulna 
Avith  his  knee,^so  as  to  separate  them  from  the  os 
humeri,  and  thus  the  coronoid  process  is  tlirownfrom 
the  posterior  fossa  of  the  humerus ;  whilst  this 
pressure  is  supported  bj  the  knee,  the  arm  is  to  be 
forcibly,  but  slowly  bent,  and  the  reduction  is  soon 
effected.  It  may  be  also  accomplished  by  placing 
the  arm  around  the  post  of  a  bedstead,  and  by  forc- 
ibly bending  it  while  it  is  thus  confined.  I  have  also 
reduced  the  limb  by  making  the  patient,  whilst 
placed  upon  an  elbow-chair,  put  his  arm  through  the 
opening  in  its  back,  and  then,  having  bent  the  arm, 
the  body  and  limb  being  thus  well  fixed,  the  reduc- 
tion was  easily  effected. 

This  dislocation  is  sornetimes  undiscovered  at  first, 
in  consequence  of  the  great  tumefaction  which  im- 
mediately succeeds  the  injury;  but  this  circumstance 
does  not  prevent  the  reduction,  even  at  the  period 
of  several  weeks  after  the  accident  :  for  I  have 
known  it  then  eflected  by  bending  the  limb  over  the 
knee,  even  without  the  application  of  very  great 
force. 

j^Jter 'treatment. —  As  soon  as  the  reduction  has 
been  accomplished,  the  arm  should  be  bandaged  in 
the  bent  position;  evaporating  lotions  should  be  ap- 
plied, and  the  limb  be  supported  in  a  sling;  the  fore 
arm  should  be  bent  at  rather  less  than  a  right  angle 
with  the  upper  arm.  A  splint  may  be  placed  in  the 
sling,  for  the  better  support  of  the  limb. 


COMPOUND  dislocation   OF  THE  OS  HUMERI  AT  THE 
ELBOW-JOINT. 

Case. —  William  Dawson,  aged  thirteen,  was  ad- 
mitted into  the  accident  ward  of  Guy's  Hospital  on 


432  DISLOCATIONS  OF  THE  ELBOW-JOINT. 


the  5th  of  November,  1822,  at  twenty  minutes  past 
seven  o'clock  in  the  evening,  with  coiji pound  disloca- 
tion of  the  elbow-joint,  occasioned  by  the  overturn- 
ing of  a  cart  in  which  he  was  riding,  and  which  fell 
with  great  violence  upon  the  elbow  of  the  left  arm. 

The  appearances  were  as  follow  :  The  condyles 
of  the  humerus  were  thrown  inwards  through  the 
skin,  the  articulating  surface  receiving  the  sigmoid 
cavity  of  the  ulna  being  completely  exposed  to  view  ; 
the  ulna  was  dislocated  backwards,  and  the  radius 
outwards;  the  lateral  and  capsular  ligaments  were 
torn  asunder,  with  extensive  laceration  of  the  parts 
about  the  joint,  but  the  artery  and  nerve  remained 
perfectly  free  from  injury. 

By  the  kind  assistance  of  Mr  Key  the  reduction 
was  easily  effected  in  the  following  manner.  The 
humerus  being  firmly  grasped  above  its  condyles, 
making  that  part  a  fixed  point,  we  gradually  extend- 
ed the  fore  arm  from  the  position  in  which  it  was 
found  (at  right  angles),  and  the  parts  returned  to 
their  relative  situation;  but  upon  slightly  moving 
the  fore  arm,  they  became  displaced  as  before  ;  but 
the  reduction  was  effected  a  second  time  as  above 
described,  and  in  the  semiflexed  position  the  arm 
was  dressed  with  adhesive  plaster,  and  a  paste- 
board splint  put  on,  previously  dipped  in  warm 
water,  so  as  to  give  it  pliabihty  in  order  to  adapt 
it  to  the  form  of  the  part ;  a  roller  was  then 
applied,  and  a  sling  was  attached  to  the  wrist  and 
conveyed  round  the  neck,  by  which  means  the  pa- 
tient was  prevented  from  moving  the  arm  from  the 
posture  in  which  it  was  placed.  He  was  then  laid 
recumbent,  with  the  elbow  resting  on  a  pillow  ;  and 
the  evaporating  lotion  of  our  hospital  Avas  euiployed, 
to  keep  the  parts  constantly  moist  and  cool.  I  saw 
him  during  the  night,  and  found  that  he  was  gene- 


DISLOCATIONS   OF  THE  ELBOW-JOINT.  433 

rally  composed,  and  had  slept.  Early  the  next  morn- 
ing he  was  free  from  pain,  his  pulse  112;  he  expe- 
rienced much  thiF'st  during  the  day,  without  any 
other  unpleasant  symptoms,  except  some  tension  of 
the  parts,  hy  no  means  considerable.  On  the  fol- 
lowing morning,  there  being  some  symptoms  of  in- 
flammation, accompanied  with  pain  in  the  head,  I 
drew  from  the  right  arm  ten  ounces  of  blood,  whicfi 
appeared  to  relieve  him  ;  in  the  evening  of  the  same 
day  he  was  restless,  and  complained  of  great  thirst; 
small  quantities  of  barley  water  were  given  to  him, 
and  in  the  evening  three  grains  of  hydrag  :  submui'. 
He  slept  during  the  night,  and  on  the  following 
morning  the  pulse  had  risen  to  121  ;  febrile  action 
appearing,  the  julepum  ammon  :  acet :  was  given  to 
him  every  three  or  four  hours,  and  in  the  evening 
his  pulse  had  fallen  to  109  ;  he  complained  of  dart- 
ing pains  in  the  shoulder,  and  his  bowels  being  in  a 
constipated  state,  I  gave  him  3  iij.  of  ol  :  ricini,  and 
two  hours  afterwards  he  had  a  copious  evacuation, 
from  which  he  felt  easier  and  much  relieved,  and  he 
passed  a  good  night.  On  the  following  day  I  found 
him  free  from  pain  and  much  better.  The  next 
day  (Sunday)  he  complained  of  slight  pains  in  the 
upper  arm,  accom})anied  with  a  small  discharge  from 
the  wound.  On  the  following  day  he  was  better, 
pulse  105;  and  on  Tuesday  the  discharge  had  in- 
creased, but  on  the  three  following  days  it  decreas- 
ed, when  I  ventured  to  dress  the  wound  :  the  granu- 
lations were  extremely  healthy;  the  parts  appeared 
to  be  well  adjusted,  leaving  only  a  small  sinus,  by 
which  the  discharge  escaped.  It  was  again  dressed 
as  at  first,  with  the  exception  of  the  splint  :  the 
lotion  was  discontinued,  the  parts  being  perfectly 
cool,  and  the  tension  much  reduced.  The  bowels 
being  confined,  the  ol.  ricini  was  repeated,  which 
procured  him  two  stools.  On  the  following  day  he 
55 


434  DISLOCATIONS  OF  THE  ELBOW-JOINT. 


complained  of  pains  in  the  slioulder ;  tlie  discharge 
was  again  increasing;  but  on  the  four  following  days 
he  proceeded  well,  the  pulse  varying  from  98  to 
109.  On  the  sixth  day  from  the  first  dressing  I  pro- 
ceeded to  repeat  that  operation  ;  the  granulations 
were  rather  prominent,  but  healthy  ;  and  the  wound 
was  dressed  with  straps  of  soap  cerate.  During  the 
six  following  days  the  patient  continued  to  get  better; 
but  on  the  seventh  day  from  the  second  dressing  of 
the  wound,  some  inflammation  appeared,  and  the 
lotion  w^as  renewed  :  the  discharge  at  this  time  was 
very  slight.  On  examining  the  part,  an  abscess  had 
formed  upon  the  external  condyle,  which  1  relieved 
in  a  day  or  two  after  by  the  lancet:  the  quantity  of 
matter  discharged  was  about  sij,  but  quite  healthy. 
The  next  day  he  was  much  better ;  and  from  this 
time  he  continued  improving  until  the  24th  of 
December,  on  which  day  he  was  able  to  leave  his 
bed,  and  walk  about  the  ward.  By  great  attention 
to  the  use  of  passive  motion,  he  is  now  enabled  to 
move  the  joint  to  a  considerable  extent. 

Samuel  White, 

Dresser  at  Guifs  Hospital. 

1  frequently  witnessed  the  progress  of  this  case 
with  the  greatest  pleasure.  —  A.  C. 


LATERAL  DISLOCTION  OF  THE  ELBOW. 

JYature  of  the  accident.  —  In  this  case  the  ulna,  in- 
stead of  being  thrown  into  the  posterior  fossa  of  the 
OS  humeri,  has  its  coronoid  process  situated  on  the 
back  part  of  the  external  condyle  of  the  humerus. 
The  projection  of  the  ulna  backwards  is  greater  in 
this  than  in  the  former  dislocation,  and  the  radius  forms 
a  protuberance  behind  and  on  the  outer  side  of  the 


DISLOCATIONS  OF  THE  ELBOW-JOINT. 


435 


OS  humeri,  so  as  to  produce  a  hollow  above  it ;  the 
rotation  of  the  head  of  the  radius  is  distinctly  felt  by 
rolling  the  hand.  Sometimes  the  ulna  is  thrown 
upon  the  internal  condyle  of  the  os  humeri,  so  as  to 
produce  an  apparent  hollow  above  it ;  the  rotation 
of  the  head  of  the  radius  is  distinctly  felt  by  rolling 
the  hand.  Sometimes  the  uhia  is  thrown  upon  the 
internal  condyle  of  the  os  humeri,  but  it  still  pro- 
jects posteriorly,  as  in  the  external  dislocation;  and 
then  the  head  of  the  radius  is  placed  in  the  pos- 
terior fossa  of  the  humerus.  The  external  condyle 
of  the  OS  humeri  in  this  case  projects  very  much 
outwards.  I  have  never  had  an  opportunity  of  dis- 
secting this  injury. 

Causes  of  the  accident.  —  The  manner  in  which 
the  lateral  dislocation  is  produced  is  the  same  as  in 
that  directly  backwards,  hut  the  direction  of  the  fall 
is  varied  ;  it  is  also  caused  by  the  wheel  of  a  car- 
riage passing  over  the  arm  whilst  it  is  placed  upon 
uneven  ground.  The  reduction  of  each  may  be  effect- 
ed as  in  the  former  dislocation,  by  bending  the  arm 
over  the  knee,  even  without  particularly  attending 
to  the  direction  of  it  inwards  or  outwards  ;  for  as 
soon  as  the  radius  and  ulna  are  separated  from  the 
OS  humeri  by  the  pressure  of  the  knee,  the  muscles 
give  them  the  proper  direction  for  reduction.  But 
in  a  recent  injury  the  bones  may  be  more  easily  re- 
duced in  the  following  manner. 

Case.  —  A  lady  consulted  me  respecting  a  frac- 
ture of  the  patella,  which  had  united  by  a  long  liga- 
ment ;  and  I  told  her  to  be  careful  to  wear  a  band- 
age, as  she  was  very  liable  to  fall  and  to  break  the 
other  patella,  which  I  have  frequently  known  to 
happen.  This  was  at  ten  o'clock,  in  the  morning; 
at  two  o'clock  she  came  to  me  at  Guy's  Hospital, 
having  her  elbow  dislocated  backwards,  and  also 
laterally  inwards.  Finding  that  the  tendon  of  the 
biceps,  and  (as  I  knew)  the  brachialis  internus,  were 


436 


DISLOCATIONS  OF  THE  ELBOW-JOINT. 


put  upon  the  stretch,  I  thought  I  might  make  use  of 
ihem  to  draw  the  os  humei  i  backwards,  as  by  the 
string  of  a  pulley,  and  1  forcibly  extended  the  arm, 
when  tlie  dislocation  was  immediately  reduced. 

The  plate  of  the  dislocation  backwards  will  ex- 
plain the  mode  in  which  the  reduction  was  effected. 
It  will  be  there  seen  that  the  tendon  of  the  bra- 
chialis  internus  is  stretched  over  the  condyles  of  the 
humerus,  and  the  biceps  is  also  stretched  over  that 
bone  ;  so  that  if  the  fore  arm  be  forcibly  extended, 
these  muscles  force  back  the  condyles  of  the  humerus 
into  their  natural  situation. 


DISLOCATION   OF  THE   ULNA  BACKWARDS. 

Symptoms  of  this  accident.  —  The  ulna  is  some- 
times thrown  back  upon  the  os  humeri  without  being 
followed  by  the  radius.  The  appearance  of  the 
limb  is  then  much  deformed  by  the  contortion  in- 
wards of  the  fore  arm  and  hand.  The  olecranon 
projects,  and  can  be  felt  behind  the  os  humeri.  Ex- 
tension of  the  arm  is  impracticable,  but  by  a  force 
which  will  reduce  the  dislocation,  and  it  cannot  be 
bent  to  more  than  a  right  angle.  It  is  an  accident 
somewhat  difficult  to  detect;  but  its  distinguishing 
marks  are  the  projection  of  the  ulna,  and  the  twist 
of  the  fore  arm  inwards. 

Dissection;  cause. — We  have  an  excellent  speci- 
men  of  this  accident  in  the  Museum  at  St  Thomas's 
Hospital.  (See  Plate.)  It  had  existed  a  great 
length  of  time  without  reduction  ;  the  coronoid 
process  of  the  ulna  was  thrown  into  the  posterior 
fossa  of  the  humerus;  the  olecranon  is  seen  project- 
ing behind  the  os  humeri ;  the  radius  rests  upon  the 
external  condyle,  and  has  formed  a  small  socket  for 
its  head,  in  which  it  was  able  to  roll.    The  coronary 


DISLOCATIONS   OF  THE   ELBOW— JOINT. 


437 


and  oblique  ligaments  had  been  torn  through,  and 
also  a  small  part  of  the  interosseus  ligament  ;  the 
lower  extremity  of  the  internal  condyle  of  the  hu- 
merus seems  to  have  had  an  oblique  fracture  in  it ; 
but  1  doubt  whether  it  had  been  broken,  or  only 
altered  in  form,  on  account  of  the  unnatural  position 
of  the  ulna.  If  it  had  been  broken,  it  was  reunited  ; 
the  triceps  was  thrown  backwards,  and  the  brachi- 
alis  internus  muscle  was  stretched  under  the  extrem- 
ity of  the  humerus.  The  accident  arises  from  a 
severe  blow  on  the  lower  extremity  of  the  ulna, 
by  which  it  is  pushed  suddenly  upwards  and  back- 
wards. 

Mode  of  reduction.  —  This  d  islocation  is  more  easily 
reduced  than  that  of  both  bones;  and  the  best  method 
is  to  bend  the  arm  over  the  knee,  and  to  draw  the 
fore  arm  downwards;  the  reduction  will  then  be 
easy,  as  not  only  the  brachial  is  muscle  will  act  m 
resistance,  but  the  radius,  resting  against  the  exter- 
nal condyle,  will  push  the  os  humeri  backwards 
upon  the  ulna  when  the  arm  is  bent^ 


DISLOCATION  OF  THE  RADIUS  FORWARDS. 

This  bone  is  sometimes  separated  from  the  ulna 
at  their  junction  at  the  coronoid  process,  and  its  head 
is  thrown  into  the  hollow  above  the  external  condyle 
of  the  OS  humeri,  and  upon  the  coronoid  process  of 
the  ulna.    (See  Plate.) 

Symptoms  of  this  accident.  —  I  have  seen  six  ex- 
amples of  this  accident ;  its  symptoms  are  as  follow: 
The  fore  arm  is  slightly  bent,  but  cannot  be  brought 
to  a  right  angle  with  the  upper,  nor  can  it  be  com- 
pletely extended.    When  it  is  suddenly  bent,  the 


438  DISLOCATIONS   OF  THE  ELBOW-JOINT. 


head  of  the  radius  strikes  against  the  fore  part  of 
the  OS  humeri,  and  produces  so  sudden  a  stop  to  its 
motion,  as  at  once  to  convince  the  surgeon  that  one 
bone  strikes  against  the  other.  The  hand  is  placed 
in  a  prone  position,  but  neither  its  pronation  nor 
supination  can  be  completely  performed,  although 
its  pronation  be  nearly  complete.  If  the  thumb  be 
carried  into  the  fore  and  upper  part  of  the  elbow- 
joint,  the  head  of  the  radius  may  be  there  felt;  and 
if  rotation  of  the  hand  be  attempted,  the  bone  will 
be  perceived  to  roll;  this  last  circumstance,  and  the 
sudden  stop  to  the  bending  of  the  arm,  are  the  best 
diagnostic  marks  of  the  injury. 

Dissection,  —  In  the  dissection  of  this  case,  the 
head  of  the  radius  is  found  resting  in  the  hollow 
above  the  external  condyle  of  the  os  humeri  ;  the 
ulna  is  in  its  natural  situation.  The  coronary  liga- 
ment of  the  radius,  the  oblique  ligament,  and  the 
fore  part  of  the  capsular,  as  well  as  a  portion  of  the 
interosseous  ligament,  are  torn  through;  the  lacera- 
tion of  the  latter  ligament  allows  the  separation  of 
the  two  bones.  The  biceps  muscle  is  shortened  ; 
and  those  who  have  not  seen  an  example  of  this 
injury,  will  do  well  to  consult  the  preparation  from 
which  this  plate  is  taken. 

Cause  of  this  accident,  —  The  cause  of  this  acci- 
dent is  a  fall  upon  the  hand  when  the  arm  is  ex- 
tended; the  radius  receiving  the  weight  of  the  body, 
is  forced  up  by  the  side  of  the  ulna,  and  thrown 
over  the  condyle,  and  upon  the  coronoid  process  of 
the  ulna. 

Cases,  —  The  first  case  I  saw  of  this  accident  was 
in  a  woman,  who  was  a  patient  of  Mr  Cline's,  in 
St  Thomas's  Hospital,  whilst  I  was  an  apprentice  to 
him.  The  most  varied  attempts,  which  his  strong 
judgment  could  direct,  were  made  to  reduce  the 
bone,  but  they  proved  ineffectual ;  and  the  woman 


DISLOCATIONS  OF  THE  ELUOW-JOIKT. 


439 


was  discharged  from  the  hospital  with  the  disloca- 
tion unreduced. 

The  second  case  was  in  a  lad  to  whom  I  was 
called  by  Mr  Balmanno,  of  Bishopsgate-street ;  and 
although  I  made  attempts,  bj  continuiiig  and  vary- 
ing the  extension  in  every  direction  for  an  hour  and 
a  quarter,  I  could  not  succeed  in  effecting  the  reduc- 
tion. 

The  third  case  was  that  of  a  hair-dresser,  who, 
having  been  intoxicated  in  the  evening,  came  to  my 
house  on  the  following  morning  with  his  radius  dis- 
located ;  during  the  time  of  examination  the  patient 
became  faint,  and  at  last  fell  upon  the  floor  in  a 
state  of  syncope  ;  this  I  thought  afforded  me  a  most 
favourable  opportunity  for  replacing  the  bone,  and 
whilst  he  was  still  upon  the  floor  1  rested  his  ole- 
cranon upon  my  foot,  so  as  to  prevent  the  ulna  from 
receding,  and  then  extended  the  fore  arm  ;  and  under 
these  favourable  circumstances,  the  radius  returned 
to  its  natural  situation. 

Case,  —  The  fourth  case  was  that  of  a  gentleman 
in  Old  Broad-street,  to  whom  I  was  called  by  Mr 
Gordon,  of  Oxford-court,  in  the  City;  and  the  man- 
ner in  which  we  succeeded  in  the  reduction  was  as 
follows:  —  We  placed  our  patient  upon  the  sofa, 
and  bent  his  arm  over  the  back  of  it ;  then  making 
extension  from  the  hand  without  including  the  ulna, 
the  OS  humeri  being  fixed  by  the  sofa,  the  radius  in 
a  few  minutes  slipped  into  its  place. 

Case,  —  The  fifth  case  was  that  from  which  was 
made  the  preparation  preserved  in  our  collection  at 
St  Thomas's  Hospital,  and  of  which  I  have  given  a 
plate.  That  preparation  was  one  morning  lying  on 
my  chimney-piece,  when  a  gentleman  of  high  cha- 
racter at  the  bar  called  upon  me  :  he  said,  '  What 
have  you  here?'  and  when  I  mentioned  the  nature 
of  the  injury  —  'Well,  that  is  very  curious,'  said 


440 


DISLOCATIONS   OF  THE  ELBOW-JOINT. 


he  ;  '  for  I  have  mjself  been  the  subject  of  this 
accident.'  He  then  exposed  his  arm,  and  showed 
me  a  dislocation  of  the  radius:  it  had  happened 
many  years  before,  and  he  told  me  that  numerous 
and  most  violent  attempts  had  been  made  to  reduce 
it  without  success. 

The  observations  here  stated  upon  this  subject  I 
have  usually  given  in  my  lectures,  carefully  explain- 
ing the  difficulty  in  restoring  the  bone  to  its  situation. 
Once,  on  an  occasion  of  this  kind,  Mr  Williams,  one 
of  the  most  intelligent  of  my  pupils,  said  to  me,  '  I 
have  known  the  radius  reduced  in  these  accidents 
by  extending  from  the  hand  only.'  From  a  consid- 
eration of  what  he  said,  and  from  an  experiment  on 
the  dead  body,  placing  the  radius  in  the  situation  in 
which  it  is  thrown  by  this  accident,  I  was  convinced 
that  the  mode  of  extension  mentioned  by  Mr  Wil- 
liams was  the  best ;  as,  from  the  connexion  of  the 
hand  with  the  radius,  that  bone  alone  is  acted  upon; 
and  the  ulna  being  excluded  from  the  force  applied, 
the  radius  sustains  the  whole  extension.  It  is  also 
right  in  making  the  extension  to  render  the  hand 
supine,  as  this  position  draws  the  head  of  the  radius 
from  the  upper  part  of  the  coronoid  process  of  the 
ulna,  upon  which  it  would  otherwise  be  directed; 
and  then  to  draw  the  fore  arm,  by  pulling  the  hand, 
and  by  fixing  the  os  humeri. 

Mr  Tyrrel  informed  me  that  a  sailor^  about  thir- 
ty years  of  age,  came  to  St  Thomas's  Hospital,  as 
an  out-patient,  with  a  dislocation  of  the  radius  for- 
wards, which  had  happened  between  six  and  seven 
months  before.  The  head  of  the  radius  could  be 
distinctly  felt  upon  the  anterior  part  of  the  hu- 
merus, especially  when  the  arm  was  bent  as  much 
as  the  nature  of  the  accident  would  allow,  and  when 
the  hand  was  bent  as  much  as  it  could  be  towards 
the  fore  arm.    The  position  of  the  limb  was  half 


DISLOCATIONS   OF  THE  ELBOW-JOINT.  441 

supine;  and  when  the  humerus  was  fixed,  the  liand 
could  be  rendered  neither  perfectly  supine  nor 
prone.  On  the  attempt  to  flex  the  fore  arm,  a  sud- 
den check  to  its  motion  was  produced  by  the  head 
of  the  radius  striking  against  the  humerus.  From 
constant  use  of  the  arm  alter  the  accident,  consider- 
able motion  had  been  reacquired,*  yet  the  man  was 
anxious  that  an  attempt  should  be  made  to  reduce 
it,  from  which  he  was  dissuaded,  and  he  went  lo 
Guy's  Hospital,  where  the  same  advice  was  given 
to  him. 


DlSLOCA-fioN   OF  THE   RADIUS  BACKWARDS. 

appearance  of  this  accident,  —  This  is  an  acci- 
dent which  I  have  never  seen  in  the  living  person; 
but  in  the  winter  of  1821,  a  man  was  brought  for 
dissection  into  the  theatre  of  St  Thomas's  Hospital, 
in  whom  was  found  this  dislocation,  which  had 
never  been  reduced.  The  head  of  the  radius  was 
thrown  behind  the  external  condyle  of  the  os  hu- 
meri, and  rather  to  the  outer  side  of  the  lower 
extremity  of  that  bone.  Mr  Sylvester,  from  Glou- 
cester, a  very  intelligent  student,  had  the  kindness 
to  make  me  a  drawing  of  the  parts  as  they  were 
dissected,  and  the  appearances  will  be  seen  in  the 
tw^enty-sixth  plate.  When  the  arm  was  extended, 
the  head  of  the  radius  could  be  seen,  as  well  as 
felt,  behind  the  external  condyle  of  the  os  humeri. 
On  dissecting  the  ligaments,  the  coronary  ligament 
was  found  to  be  torn  througli  at  its  fore  part,  and 
the  oblique  also  had  given  way.  The  capsular 
h'gament  was  partially  torn,  and  the  head  of  the 

*  He  could,  although  with  great  difficulty,  touch  the  lips 
with  his  hand. 

5(5 


442  DISLOCATIONS   OF  THE  ELBOW-JOINT. 


radius  would  have  receded  much  more,  had  it 
not  been  supported  by  the  fascia  which  extends 
over  the  muscles  of  the  fore  arm. 

Of  the  causes  of  this  accident  1  know  nothing, 
never  having  seen  it  in  the  living  subject. 

Mode  of  reduction.  —  As  to  its  reduction,  it  will 
be  easily  effected  by  bending  the  arm  ;  but  to  se- 
cure the  bone  from  subsequent  displacement,  the 
arm  must  be  kept  steadily  bent  at  right  angles,  and 
secured  by  splints  and  a  circular  bandage  in  that 
situation,  until  the  union  of  the  coronary  ligament 
has  been  effected,  which  will  require  the  lapse  of 
three  or  four  weeks  from  the  accident. 


LATERAL  DISLOCATION  OF  THE  RADIUS. 

Mr  Freeman,  Surgeon,  of  Spring-gardens,  brought 
to  my  house  a  gentleman  of  the  name  of  Whaley, 
aged  twenty-five  years,  whose  pony  having  run  away 
with  him,  when  he  was  twelve  years  of  age,  he  had 
struck  his  elbow  against  a  tree  whilst  his  arm  was 
bent  and  advanced  before  his  head.  The  olecranon 
was  broken,  and  the  radius  dislocated  upwards  and 
outwards,  above  the  external  condyle;  and  when  the 
arm  is  bent,  the  head  of  the  radius  passes  the  os 
humeri.  He  has  a  useful  motion  of  the  arm,  but 
neither  the  flexion  nor  the  extension  is  complete. 


FRACTURES  OF  THE  ELBOW-JOINT. 


FRACTURES  ABOVE  THE    CONDYLES  OP    THE   OS  HUMERI. 

The  condyles  of  the  os  humeri  are  sometimes 
obliquely  broken  off  just  above  the  joint,  and  the 
appearance  produced  is  so  similar  to  that  of  the  dis- 
location of  the  radius  and  ulna  backwards,  that  this 
fracture  is  very  liable  to  be  mistaken  for  that  injury. 
The  following  case  will  best  exemplify  its  diagnostic 
marks. 

Case. —  William  Law,  aged  nine  years,  was  ad- 
mitted into  Guy's  Hospital  on  the  3rd  of  July,  1822, 
with  a  fracture  of  the  condyles  of  the  os  humeri  , 
above  the  elbow-joint,  which  he  had  sustained  in 
being  thrown  from  a  cart,  having  fallen  upon  his 
elbow.  At  the  time  of  his  admission  the  arm  was 
slightly  bent,  and  the  radius  and  ulna  appeared  to 
project  considerably  backwards;  just  above  the 
projection  there  was  a  hollow  in  the  back  of  the 
arm,  so  that  the  appearances  much  resembled  those 
of  dislocation.  I  extended  the  fore  arm,  and  the 
appearances  of  the  dislocation  ceased;  but  when  the 
extension  was  discontinued,  those  appearances  re- 


444 


FRACTURES  OF  THE  ELBOW-JOINT. 


turned.  At  this  time  Mr  Key  arrived,  who  explained 
the  accident  to  be  a  fracture  above  the  condyles. 
The  arm  was  put  in  splints,  which  were  constantly 
worn  until  the  13th  of  July,  when  they  were  occa- 
sionally removed,  and  passive  motion  was  employed. 
D.  B.  Major, 

Dresser,  Guy^s  Hospital, 

Diagnostic  marks  of  the  nature  of  this  accident, — 
The  appearances  of  this  accident,  as  will  be  seen, 
are  like  those  of  dislocation  of  the  radius  and  ulna 
backwards;  and  the  mode  of  distinguishing  the  two 
injuries  is,  by  the  removal  of  all  the  marks  of  dislo- 
cation on  extension,  and  by  their  return  so  soon  as 
the  extension  is  discontinued  ;  in  general,  also,  these 
accidents  are  detected  by  rolling  the  fore  arm  upon 
the  humerus,  when  a  crepitus  may  be  felt  just  above 
the  elbow-joint. 

The  'period  of  life  at  which  the  accident  happens 
most  yre^?«e72^/?/.  —  This  fracture  happens  at  all  pe- 
riods of  life,  but  much  more  frequently  in  children 
than  in  persons  of  advanced  age. 

Treatment.  —  Its  treatment  consists  in  bending  the 
arm,  and  drawing  it  forwards  to  effect  replacement; 
then  a  roller  should  be  applied  while  it  is  in  the 
bent  position.  The  best  splint  for  it  is  one  formed 
at  right  angles,  of  which  the  upper  portion  should 
be  placed  behind  the  upper  arm,  and  the  lower  por- 
tion under  the  fore  arm;  a  splint  must  also  be  plac- 
ed npon  the  fore  part  of  the  upper  arm,  and  both 
should  be  confined  by  straps;  evaporating  lotions 
should  be  used,  and  the  arm  kept  in  the  bent  posi- 
tion by  a  shng.  In  a  fortnight,  if  the  patient  be 
young,  passive  motion  may  be  gently  begun,  to  pre- 
vent the  occurrence  of  anchylosis  ;  and  in  the  adult, 
at  the  end  of  three  weeks,  a  similar  treatment  is  to 


FRACTURES   OF  THE  ELBOW-JOINT. 


415 


b#  pursued.  But  even  after  the  most  careful  and 
judicious  means  which  can  be  adopted,  there  is  some- 
times considerable  Joss  of  motion ;  and  when  the 
accident  has  not  been  understood  or  has  been  care- 
lessly treated,  the  deformity  and  loss  of  motion  be- 
come very  considerable.    (See  Plate.) 


FRACTURE  OF  THE  CONDYLES  OF  THE  OS  HUMERI. 

The  following  case  on  this  subject  was  sent  me 
by  Mr  Ivimy,  of  Portsea, 

My  dear  Sir:  —  Allow  me  to  recommend  to  you 
the  bearer,  Mrs  Hewett,  of  Southsea,  who  met  with 
a  severe  accident  on  the  21st  of  September  last,  by 
a  fall  from  a  chaise,  which  occasioned  a  compound 
fracture  of  the  left  arm,  of  the  following  description : 
The  external  and  internal  condyles  were  fractured 
longitudinally  ;  the  intermediate  space  which  re- 
ceives the  olecranon  was  quite  comminuted,  and 
three  pieces  of  bone  were  extracted  soon  after  the 
accident  from  the  external  wound  :  there  was  also 
a  transverse  fracture  about  two  inches  and  a  half 
above  the  condyles. 

Evaporating  lotions  were  applied  during  the  two 
first  weeks,  and  the  case  proceeded  favourably.  I 
more  particularly  call  your  attention  to  the  wrist  of 
the  right  arm,  which  was  much  injured  at  the  time 
of  the  accident ;  I  recommended  friction,  which  I  am 
afraid  has  been  neglected. 

If  time  will  permit,  your  opinion  of  the  above 
case  will  much  oblige 

Your's  respectfully, 

Thomas  Ivimy. 

Portsea,  March  5th,  1823. 


446  FRACTURES  OF  THE  ELBOW-JOINT. 


This  lady  has,  in  a  great  degree,  reacquired  Mie 
flexion  and  extension  of  the  left  arm. 

A.  C. 


FRACTURE  OF  THE  INTERNAL  CONDYLE  OF  THE  OS 
HUMERI. 

The  internal  condyle  of  the  humerus  is  frequently 
broken  obUquely  from  the  other  condyles  and  body 
of  the  bone  ;  and  the  symptoms  by  which  the  acci- 
dent is  known  are  as  follow: 

First.  The  ulna  appears  dislocated  from  it  and 
from  the  broken  condyle,  projecting  behind  the  hu- 
merus when  the  arm  is  extended. 

Secondly.  The  ulna  resumes  its  natural  situation 
in  bending  the  arm. 

Thirdly.  By  grasping  the  condyles,  and  bending 
and  extending  the  fore  arm,  a  crepitus  is  perceived 
at  the  internal  condyle. 

Fourthly.  When  the  arm  is  'extended,  the  lower 
end  of  the  os  humeri  advances  upon  the  ulna,  so  as 
to  be  felt  upon  the  anterior  part  of  the  joint. 

1  saw  a  girl,  a  patient  of  Mr  Steel,  of  Berkhamp- 
«tead,  who,  by  a  fall  upon  her  elbow,  had  fractured 
the  olecranon,  and  also  broken  the  internal  condyle 
of  the  OS  humeri,  the  point  of  the  broken  bone  hav- 
ing almost  penetrated ' the  skin;  the  cubital  nerve 
had  been  also  injured;  for  the  little  finger  and  half 
the  ring  finger  were  benumbed. 

The  cause  of  this  accident  is  a  fall  upon  the  point 
of  the  elbow.  It  usually  occurs  in  youth,  before 
the  epiphysis  is  completely  ossified;  although  I  have 
seen  it,  but  less  frequently,  in  age.  It  is  often  mis- 
taken for  dislocation. 


FRACTURES  OF  THE  ELBOW-JOINT. 


447 


Treatment,  —  Its  treatment  consists  in  applying  a 
roller  round  the  elbow-joint,  to  keep  the  bone  in 
complete  apposition  ;  in  wetting  it  frequently  with 
spirits  of  wine  and  water;  in  bending  the  limb  at  a 
right  angle,  and  supporting  it  in  a  sling;  and  in  be- 
ginning with  passire  motion,  in  the  child  at  the  ex- 
piration of  three  weeks  after  the  accident,  and  at 
the  end  of  a  month  in  the  adult,  to  prevent  loss  of 
motion  in  the  joint. 


FRACTURE  OF  THE  EXTERNAL  CONDYLE  OF  THE  OS 
HUMERI. 

Diagnostic  marks  of  this  accident,  —  This  accident 
is  readily  detected  by  the  following  symptoms: 
Swelling  upon  the  external  condyle,  and  pain  upon, 
pressure;  the  motio'ns  of  the  elbow-joint,  both  of 
extension  and  flexion,  are  performed  with  pain ;  but 
the  principal  diagnostic  sign  is,  the  crepitus  produced 
by  the  rotatory  motion  of  the  hand  and  radius.  If 
the  portion  of  the  fractured  condyle  be  large,  it  is 
drawn  a  little  backwards,  and  carries  the  radius 
with  it ;  but  if  the  portion  be  small,  this  circum- 
stance does  not  occur.  We  have  two  excellent  pre- 
parations of  this,  accident  in  the  Museum  at  St  Tho- 
mas's Hospital,  and  in  neither  case  has  there  been 
any  other  than  ligamentous  union.  In  one  prepara- 
tion, in  which  the  external  condyle  is  sj)llt  obliquely, 
the  bone  is  somewhat  thickened;  but  although  this 
accident  had  obviously  happened  long  before  death, 
no  union  but  that  by  ligament  had  been  produced. 
The  second  preparation  is  a  specimen  of  the  trans- 
verse fracture  of  the  extremity  of  the  condyle, 
within  the  capsular  ligament,  in  which  not  the  least 


448 


FRACTURES  OF  THE  ELBOW-JOINT. 


attempt  at  ossific  union  can  be  detected.  (See 
Plate.) 

It  is  obvious,  therefore,  that  this  principle  of  lig- 
amentous union  extends  to  all  detached  portions 
within  a  capsular  ligament;  the  vitality  of  the  bone 
being  supported  merely  by  the  ligament  within  the 
joint.  ^  ^ 

This  accident  usually  happens  in  children,  by 
falls  upon  the  elbow;  at  least  in  the  course  of  my 
observation,  a  very  large  proportfon  of  the  cases 
have  been  in  young  persons  :  I  have  seen  it  occur 
in  the  adult,  but  very  rarely  in  advanced  age. 

Treatment.  —  The  treatment  required  is  the  fol- 
lowing :  A  roller  is  applied  around  the  elbow,  and 
above  and  below  the  joint.  An  angular  splint  is  to 
be  adapted,  which  should  admit  the  elbow,  extend 
behind  the  upper  arm,  and  receive  the  fore  aim 
(see  Plate),  so  as  to  support  it ;  a  roller  should  then 
be  bound  over  the  whole  to  keep  it  firmly  fixed. 
In  the  child  this  splint  may  be  made  of  stiff  paste- 
board, bent  to  the  shape  of  the  elbow  ;  but  the  best 
mode  for  its  application  is,  to  dip  it  in  hot  water 
and  apply  it  wet,  so  that  it  may  exactly  adapt  itself 
to  the  form  of  the  limb ;  it  thus  becomes  the  best 
possible  support  to  the  injured  arm.  Indeed,  it  may 
be  here  observed,  that  for  children  this  is  the  best 
mode  of  making  every  support  of.  this  kind.  The 
splint  is  to  be  worn  for  three,  weeks,  when  pas- 
sive motion  is  to  be  begun;  it  must  be  very  gen- 
tie  at  first,  and  may  be  gradually  increased  as  the 
pain  and  inconvenience  attending  it  subside. 

Result  of  this  injury.- — The  result  of  the  case 
depends  upon  the  seat  of  the  fracture  :  if  the  bone 
be  broken  very  obliquely,  a  steady  and  long  con- 
tinued support  of  the  part  will  occasion  it  to  unite; 
for  in  these  cases  a  considerable  portion  of  the 
fracture  is  external  to  the  capsular  ligament ;  but 


FRACTURES  OF  THE  ELBOW-JOINT. 


449 


if  the  whole  extent  of  the  fracture  be  within  the 
ligament,  it  does  not,  so  far  as  I  have  seen,  unite  by 
bone,  whatever  be  the  means  employed. 


FRACTURE  OF  THE  CORONOID  PROCESS  OF  THE  ULNA. 

A  gentleman  came  to  London  for  the  opinion  of 
different  surgeons  upon  the  following  case. 

Appearances  of  the  fracture  of  the  coronoid  pro- 
cess of  the  ulna.  —  This  gentleman  had  fallen  upon 
his  hand  whilst  in  the  act  of  running ;  and  on  rising, 
he  found  his  elbow  incapable  of  being  bent,  nor 
couid  he  entirely  straighten  it ;  he  applied  to  his 
surgeon  in  the  country,  who,  upon  examination, 
found  that  the  ulna  projected  considerably  back- 
wards; but  that  so  soon  as  he  bent  the  arm,  it  re- 
sumed its  natural  form.  He  immediately  confined 
the  limb  in  a  splint,  and  kept  it  in  a  sling.  When 
I  saw  this  gentleman  in  town,  several  months  had 
elapsed  since  the  accident,  yet  the  same  appear- 
ances, which  the  surgeon  described  when  he  first 
saw  the  injury,  remained ;  namely,  the  ulna  pro- 
jected backwards  whilst  the  arm  was  extended,  but 
it  was  without  much  difficulty  drawn  forwards  and 
bent,  and  the  deformity  was  then  removed.  It  was 
thought,  at  the  consultation  which  was  held  about 
him  in  London,  that  the  coronoid  process  was  de- 
tached from  the  ulna,  and  that  thus,  during  exten- 
sion, the  ulna  slipped  back  behind  the  inner  condyle 
of  the  humerus. 

Case  ;  dissection,  —  I  had  been  several  years  in 
the  habit  of  mentioning  this  case  at  lecture,  when  a 
person  was  brought  to  the  dissecting  room  at  St 
Thomas's  Hospital,  who  had  been  the  subject  of  the 
same  accident,  and  the  joint  is  preserved  in  our 

57 


450 


FRACTURES  OF  THE  ELBOW-JOINT. 


museum.  (See  Plate.)  The  coronoid  process,  which 
had  been  broken  off  within  the  joint,  had  united  by 
ligament  only,  so  as  to  move  readily  upon  the  ulna, 
and  thus  alter  the  sigmoid  cavity  of  the  ulna  so 
much  as  to  allow  in  extension,  that  bone  to  glide 
backwards  upon  the  condyles  of  the  humerus. 

Treatment, —  As  to  the  treatment  of  this  accident, 
I  am  doubtful  whether  any  mode  can  completely 
succeed,  as  the  coronoid  process,  like  the  head  of 
the  thigh-bone,  loses  its  ossific  nourishment,  and  has 
no  other  than  a  ligamentous  support.  Its  life  is  pre- 
served by  the  vessels  of  the  reflected  portions  of 
the  capsular  ligament  upon  the  end  of  the  bone, 
which  do  not  appear  capable  of  supporting  the  least 
attempt  at  ossific  union;  nor  is  any  change  on  the 
surface  of  the  bone  apparent.  It  will  be  proper, 
however,  in  this  accident,  to  keep  the  arm  steadily 
in  the  bent  position  for  three  weeks  after  the  inju- 
ry, and  thus  to  make  the  ligamentous  union  as  short 
as  possible,  by  leaving  the  bone  perfectly  at  rest* 


FRACTURE  OF  THE  OLECRANON. 

Symptoms  of  fracture  of  the  olecranon,  —  This  pro- 
cess of  the  ulna  is  not  unfrequently  broken  off,  and 
the  accident  is  followed  by  symptoms  which  render 
the  injury  so  evident,  that  the  nature  of  the  case 
can  scarcely  be  mistaken.  Pain  is  felt  at  the  back 
of  the  elbow,  and  a  soft  swelling  is  soon  produced 
there,  through  which  the  surgeon's  finger  readily 
sinks  into  the  joint ;  the  olecranon  can  be  felt  in  a 
detached  piece,  elevated  sometimes  to  half  an  inch, 
and  sometimes  to  two  inches,  above  the  portion  of 
the  ulna,  from  which  it  has  been  broken.  This  ele- 
vated portion  of  bone  moves  readily  from  side  to 


FRACTURES  OF  THE  ELBOW-JOINT. 


451 


side,  but  is  with  great  difficulty  drawn  downwards  ; 
if  the  arm  be  bent,  the  separation  between  the  ulna 
and  the  olecranon  becomes  much  greater.  The  pa- 
tient has  scarcely  any  powe*r  to  extend  the  limb,  and 
the  attempt  produces  very  considerable  pain;  but 
he  bends  it  with  facility,  and  if  the  limb  be  undis- 
turbed, it  is  prone  to  remain  in  the  semifle:ied  posi- 
tion. For  several  days  after  the  injury  has  been 
sustained,  much  swelling  of  the  elbow  is  produced; 
there  is  an  appearance  of  ecchymosis  to  a  consider- 
able extent,  and  an  effusion  of  fluid  ensues  into  the 
joint  in  a  much  larger  quantity  than  is  natural ; 
but  the  extent  to  which  these  symptoms  proceed, 
depends  upon  the  violence  which  produced  the  ac- 
cident. The  rotation  of  the  radius  upon  the  ulna 
is  still  preserved.  No  crepitus  is  felt,  unless  the 
separation  of  the  bone  be  extremely  slight. 


Dissection  of  this  Accident. 

Appearances  of  the  dissection  of  this  accident.  — 
This  fracture  is  usually  i'ound  to  have  happened 
through  the  centre  of  the  olecranon;  and  it  is  most 
frequently  in  the  transverse  direction;  but  I  have 
seen  the  bone  broken  obliquely,  so  that  the  fractured 
parts  presented  very  thin  edges.  On  that  portion 
of  the  olecranon  attached  to  the  ulna  there  are  some 
marks  of  ossific  inflammation,  and  some  very  slight 
traces  of  it  on  the  detached  portion.  The  cancel- 
lated structure  of  the  fractured  olecranon  is  filled  by 
ossific  matter,  and  is  sometimes  smoothed  by  occa- 
sional friction.  The  os  humeri  and  radius  undergo  no 
change.  In  the  appearances  of  one  case  which  I 
dissected,  and  of  which  I  have  given  a  plate,  the 
olecranon  is  separated  two  inches  from  the  ulna;  the 
capsular  ligament  of  the  elbow-joint  is  torn  through 


452 


FRACTURES  OF  THE  ELBOW-JOINT. 


on  each  side  of  the  olecranon;  and  the  separated 
portion  is  united  by  a  ligamentous  band,  which  is 
stretched  from  one  broken  extremity  of  the  bone  to 
the  other.    (See  Plate,) 

Mode  of  union.  —  The  nature  of  this  injury  then 
is  as  follows.  So  soon  as  the  extremity  of  the  bone 
is  broken  off,  it  is,  by  the  action  of  the  triceps  muscle, 
drawn  up  from  half  an  inch  to  two  inches  from  the 
ulna,  and  the  extent  of  its  separation  depends  upon 
the  degree  of  laceration  of  the  capsular  ligament, 
and  of  that  portion  of  the  ligamentous  band  which 
proceeds  from  the  side  of  the  coronoid  process  of 
the  ulna  to  that  of  the  olecranon.  That  I  might 
perfectly  understand  the  nature  of  this  accident,  and 
its  means  of  reparation,  I  tried  the  following  experi- 
ments on  a  dog. 

Experiments. 

The  integuments  having  been  drawn  laterally  and 
firmly  over  the  end  of  the  olecranon,  I  made  a  small 
incision,  and  placed  a  knife  upon  the  middle  of  that 
process,  in  a  transverse  direction;  on  striking  it  with 
a  mallet,  the  bone  was  readily  cut  through  ;  a  sepa- 
ration directly  took  place  by  the  action  of  the  triceps 
muscle;  adhesive  matter  was  effused;  and  when  I 
examined  the  limb  a  month  afterwards,  I  found  the 
bone  united  by  a  strong  ligament.  I  broke  the  ole- 
cranon in  the  same  manner  in  several  rabbits:  in 
these  experiments  blood  was  first  thrown  out,  and 
then  adhesive  matter  filled  up  the  space  of  separa- 
tion, which  subsequently  became  ligamentous,  and 
firmer  and  firmer,  as  the  time  was  protracted  be- 
tween the  experiment  and  the  examination. 

Formation  of  ligament  ;  union  in  fractured  olecra- 
non^ Src.  —  As  I  found  that  ligament  was  formed  in 
each  of  these  experiments,  I  was  anxious  to  learn 
whether  the  olecranon  could  be  made  to  unite  by 


FRACTURES  OF  THE  ELBOW-JOINT.  453 


bone,  if  a  longitudinal  fracture  were  produced  with 
but  slight  obliquity,  so  that  the  broken  portions  might 
still  remain  in  contact ;  and  I  found  that  under  these 
circumstances  the  osseous  union  readily  took  place. 
Therefore  this  bone,  like  the  extremity  of  the  os 
calcis  when  it  is  broken  off,  is  detached  by  the 
action  of  muscles,  and  ligamentous  union  ensues  from 
want  of  adaptation ;  but  a  different  cause  exists  where 
bony  union  fails  in  fractured  bones  within  joints  in 
the  neck  of  the  thigh-bone,  in  the  coronoid  process 
of  the  ulna,  and  in  the  extremity  of  the  external 
condyle  of  the  os  humeri.  In  these  injuries  the  want 
of  union  proceeds  from  the  diminished  support  which 
the  fractured  parts  receive,  the  little  that  exists 
being  derived  through  the  medium  of  blood-vessels 
intended  for  the  nourishment  of  ligament.  The  pre- 
parations made  from  these  experiments  may  be  seen 
in  the  Museum  at  St  Thomas's  Hospital.  I  have 
also  seen  this  bone  in  the  living  person  united  by 
an  ossific  process,  when  the  fracture  has  happened 
very  near  to  the  shaft  of  the  ulna. 

The  ligamentous  substance,  which  generally  forms 
the  bond  of  union  in  these  cases,  is  often  incomplete  ; 
having  an  aperture,  and  sometimes  several  apertures 
in  it,  when  it  is  of  considerable  length.  The  arm  is 
weakened  in  proportion  to  the  length  of  the  liga- 
ment ;  for  if  this  be  very  long,  extension  of  the  arm 
is  rendered  difficult,  from  the  necessarily  diminished 
power  of  the  triceps  muscle. 

Causes  of  this  injury.  —  The  causes  of  this  injury 
are,  first,  a  fall  upon  the  elbow  when  the  joint  is 
bent ;  and  secondly,  fracture  by  the  action  of  the 
triceps  muscle  only,  when  a  great  and  sudden  exer- 
tion is  made  during  the  flexed  position  of  the  arm. 

Treatment  of  fracture  of  the  olecranon.  —  The  treat- 
ment of  this  accident  is  as  follows,  but  it  is  to  be 


454 


FRACTURES   OF  THE  ELBOW-JOINT. 


modified  according  to  the  degree  of  injury:  —  If 
there  be  much  swelling  and  contusion,  it  is  right  to 
apply  evaporating  lotions  and  leeches  for  two  or 
three  days  ;  and  after  the  inflammation  is  reduced, 
a  bandage  should  be  applied ;  but  in  those  cases 
where  but  little  violence  is  done  to  the  limb,  it 
should  be  at  once  secured  by  bandage.  The  prin- 
ciple of  the  treatment  is  to  preserve  the  power  of 
the  limb,  by  making  the  separation  of  the  bones  as 
slight  as  possible,  that  their  ligamentous  union  may 
be  shortened ;  and  secondly,  to  restore  the  natural 
motions  of  the  joint.  If  the  swelling  and  inflamma- 
tion do  not  prevent  it,  the  surgeon  is  to  place  the 
arm  in  a  straight  position,  and  to  press  down  the 
upper  portion  of  the  fractured  olecranon  until  he 
brings  it  in  contact  with  the  ulna;  a  piece  of  linen 
is  then  laid  longitudinally  on  each  side  of  the  joint, 
a  wetted  roller  is  applied  above  the  elbow,  and 
another  below  it ;  the  extremities  of  the  linen  are 
then  to  be  doubled  down  over  the  rollers  and  tightly 
tied,  so  as  to  cause  an  approximation  ;  thus  the 
bones  are  brought  and  held  together  :  a  splint,  well 
padded,  is  to  be  applied  upon  the  fore  part  of  the 
arm,  to  preserve  it  in  a  straight  position,  and  is.to  be 
confined  to  it  by  a  circular  bandage  :  the  whole  is 
to  be  frequently  wetted  with  spirits  of  wine  and 
water. 

This  is  the  only  injury  of  the  elbow-joint  which 
requires  the  straight  position:  those  of  the  condyles 
and  coronoid  process  demanding  that  the  limb  should 
be  kept  bent. 

In  a  month  the  splint  is  to  be  removed,  and  pas- 
sive motion  is  to  be  begun  ;  but  if  it  be  attempted 
earlier,  the  olecranon  will  separate  from  the  shaft 
of  the  bone,  and  the  ligament  become  lengthened 
and  weakened-  All  attempts  at  motion  must  be 
made  with  the  greatest  gentleness. 


FRACTURES  OF  THE  ELBOW-JOINT. 


455 


Fracture  of  the  olecranon  an  inch  from  the  point 
of  the  elbow  into  the  body  of  the  ulna,  requires  the 
same  treatment  as  the  common  fracture  of  this  por- 
tion of  bone. 

Miss  ,  aged  thirty,  fell  from  her  horse  on  her 

elbow,  and  broke  the  ulna  one  inch  from  the  point 
of  the  olecranon.  It  was  kept  bent  three  months, 
and  no  extension  could  be  produced  by  any  effort  of 
herself.  I  forcibly  straightened  the  arm,  and  kept 
it  so  by  a  wooden  splint.  Bony  union  may,  in  this 
case,  be  readily  produced. 

The  subjoined  plate  is  intended  to  show  the  band 
of  ligamentous  fibres,  which,  if  it  remains  untorn, 
prevents  the  olecranon  from  separating  far  from  the 
ulna.  In  general,  however,  by  bending  the  arm,  the 
fracture  of  the  olecranon  is  easily  discovered. 

A  band  of  ligamentous  fibres  crosses  from  the  side 
of  the  coronoid  process  to  the  olecranon  ;  and  upon 
the  radial  side  of  the  ulna,  the  upper  portion  of  the 
coronary  ligament  of  the  radius  passes  from  the 
side  of  the  olecranon  towards  the  neck  of  the  ra- 
dius. If  the  olecranon  be  broken  off,  and  these 
ligamentous  fibres  be  left  entire,  the  olecranon  will 
remain  still  united  to  the  ulna  by  means  of  these 


456 


FRACTURES  OF  THE  ELBOW-JOINT. 


ligamentous  productions,  which  I  should  not  have 
noticed,  but  for  their  influence  on  fractures  of  this 
bone. 


a.  Os  humeri. 
h.  Radius. 

c.  Ulna. 

d.  Olecranon. 

c.  External  condyle  of  the  os 

humeri. 
/.  Internal  condyle. 

g.  Coronary  ligament,  the  upper 
part  of  which  ascends  to- 
wards the  olecranon. 


h.  Ligamentous  fibres  from  the 
coronoid  process  to  the  ole- 
cranon. If  the  olecranon  be 
broken  off  at  the  dotted  line, 
and  the  upper  part  of  the  co- 
ronary hgament,  and  these 
ligamentous  fibres  remain  en- 
tire, the  bone  moves  later- 
ally, but  it  separates  little 
from  the  ulna. 


FRACTURES  OF  THE  ELBOW-JOINT. 


457 


COMPOUND  FRACTURE  OF  THE  OLECRANON. 

In  compound  fractures  of  this  bone,  the  edges  of 
the  skin  must  be  brought  into  exact  apposition;  h'nt, 
embued  in  blood,  must  be  applied  on  the  wound, 
with  adhesive  plaster  over  it,  and  union  by  adhesion 
must  be  elFected  li  possible;  but  in  oilier  respects 
the  treatment  is  the  same  as  in  simple  fracture. 

I  have  seen  two  cases  of  this  accident,  both  of 
which  have  been  successfully  treated. 


FRACTURE  OF  THE  NECK  OF  THE  RADIUS. 

This  fracture  I  have  heard  mentioned  by  surgeons 
as  being  of  frequent  occurrence,  but  there  must  be 
some^  mistake  in  the  statement,  for  it  is  an  accident 
which  I  have  never  seen;  and  if  instances  ever 
present  themselves  (which  I  do  not  mean  to  deny), 
they  must  be  very  rare. 

Diagnostic  marks  of  this  accident.  —  The  injury 
would  be  known  by  fixing  the  external  condyle  of 
the  humerus  and  rolling  the  radius,  when  a  crepitus 
would  be  perceived. 

If  such  an  accident  should  occur,  the  treatment 
which  it  will  require  will  be  the  same  as  that  which 
is  demanded  for  fracture  of  the  external  condyle  of 
the  OS  humeri. 

58 


458 


FRACTURES  OF  THE  ELBOW-JOINT. 


COMPOUND  FRACTURES  AND  DISLOCATIONS  OF  THE  ELBOW- 
JOINT. 

Generally  not  destructive. — These  generally  happen 
through  the  internal  condjles  of  the  os  humeri,  and 
the  fracture  takes  an  obhque  direction  into  the  joint. 
In  the  most  severe  accident  of  this  kind,  the  consti- 
tution is  generally  able  to  support  the  injury,  if  it  be 
judiciously  treated  ;  and  the  recital  of  the  following 
cases  will  evince  the  happy  result  that  may  be  ex- 
pected, if  union  by  adhesion  be  effected  in  the  treats 
ment. 

Case,  —  I  was  called  to  Guy's  Hospital,  to  see  a 
brewer's  servant,  who  had  a  compound  fracture  of 
the  elbow-joint,  caused  by  his  dray  passing  over 
the  arm,  which  had  considerably  comminuted  the 
bones.  I  could  pass  my  finger  readily  into  the  joint, 
and  feel  the  brachial  artery  pulsating  on  its  fore^part. 
Considering  the  violence  done  to  the  part,  and  the 
constitution  of  the  patient,  who,  like  most  of  those 
in  such  employment,  drank  much  porter  and  spirits, 
and  ate  but  little,  I  at  once  told  him,  I  feared 
there  was  scarcely  any  hope  of  his  recovery,  un- 
less he  consented  to  the  loss  of  His  limb;  the  man, 
however,  determined  not  to  submit  to  the  opera- 
tion, although  Dr  Hulme,  who  accompanied  me, 
also  endeavoured  to  convince  him  of  the  necessity 
of  amputation;  I  therefore  did  all  in  my  power  to 
save  both  his  life  and  his  limb.  The  bones  were 
easily  replaced,  and  the  parts  were  carefully  brought 
together.  The  limb  was  laid  upon  a  splint,  lightly 
bandaged,  and  placed  at  right  angles.  The  wound 
united  without  any  untoward  circumstance;  and  the 
only  check  that  interrupted  his  progressive  recovery, 
was  the  formation  of  an  abscess  in  the  shoulder, 


Fractures  of  the  elbow- joint*. 


459 


which  was  opened,  and  immediately  healed.  The 
elbow-joint  was  not  even  completely  anchylosed,  for 
he  retained  sufficient  motion  in  it  to  allow  him  to  re- 
sume his  former  occupation. 

Case,  —  A  gentleman,  of  the  name  of  Stewart,  was 
thrown  from  his  chaise,  and  had  a  fracture  of  the 
condyles  of  the  os  humeri,  with  a  projection  of  a 
portion  of  its  inner  condyle  through  the  integuments. 
The  edges  of  the  wound  were  immediately  brought 
together,  and  lint,  dipped  in  blood,  was  laid  over 
them;  evaporating  lotions  were  then  applied,  and 
the  limb  was  kept  in  the  bent  position  until  the  frac- 
ture was  united.  He  had  some  use  of  the  joint 
afterwards,  but  its  motions  were  much  more  limited 
than  in  the  former  case. 

Case. — MrL — ^ — ,  aged  seventy-four,  who  is  nearly 
my  opposite  neighbour,  in  New-street,Spring-gardens, 
fell  down  some  steps  on  the  20th  of  April,  1818,  and 
shattered  his  elbow-joint.  The  condyles  were  bro- 
ken, as  well  as  the  olecranon,  and  the  internal  con- 
dyle projected  through  the  skin.  Mr  Freeman,  sur- 
geon in  New-street,  was  called  to  him,  and  he  re- 
quested me  to  attend  him.  When  I  visited  Mr  L  , 

1  found,  in  addition  to  the  above-mentioned  circum- 
stances, a  considerable  hasmorrhage  from  the  wound, 
whilst  the  comminuted  state  of  the  joint  allowed  it 
to  be  twisted  in  ail  directions. 

The  treatment  which  we  adopted  was,  to  apply 
lint  to  the  wound,  dipped  in  the  blood  which  flowed 
from  the  arm;  recourse  was  also  had  to  a  many- 
tailed  bandage,  a  pasteboard  splint,  and  an  evaporat- 
ing lotion.  As  the  parts  were  in  a  tranquil  state, 
the  dressing  was  not  disturbed  until  the  fifteenth  of 
May.  Some  matter  was  discharged  from  the  ex- 
ternal wound,  but  the  joint  never  manifested  any 
signs  of  suppuration.  The  little  discharge  that  ap- 
peared, did  not  exceed  that  which  a  small  superficial 


460  FRACTURES  OF  THE  ELBOW-sTOINT. 

wound  would  produce.  The  wound  was  some  time 
in  healing,  being  prevented  by  the  pressure  of  the 
splint,  on  which  the  arm  rested.  So  soon  as  it  was 
healed,  and  the  bones  united,  passive  motion  was 
begun;  and  although  the  form  of  the  joint  was 
irregular,  yet  a  considerable  degree  of  motion  was 
preserved. 

This  case  gratified  me  exceedingly,  the  subject  of 
the  accident  being  universally  respected  for  his 
virtues  and  his  talents;  his  constitution  was  feeble, 
his  age  advanced,  and  he  could  not  have  supported 
suppuration  of  the  elbow-joint,  nor  is  it  probable 
that  he  would  have  survived  the  loss  of  his  limb. 
By  the  simple  treatment  described,  all  the  dangers 
which  threatened  him  were  averted;  and  he  has, 
for  several  years,  survived  this  very  severe  injury. 
On  the  contrary,  if  poultices  be  applied  in  these 
accidents,  the  adhesive  process  is  prevented,  and 
suppuration  produced,  which  endangers  life,  or  ren- 
ders amputation  necessary. 

Case, —  A  woman,  between  fifty  and  sixty  years 
of  age,  was  admitted  into  Guy's  Hospital,  with  a 
wound  of  the  elbow-joint,  and  fracture  of  both  the 
condyles  of  the  os  humeri,  A  poultice  was  direct- 
ed to  be  applied,  and  fomentation  ordered  twice  a 
day.  On  the  day  following  the  accident,  she  had 
a  considerable  degree  of  fever.  On  the  third  day 
the  upper  arm  was  exceedingly  swollen,  and  there 
was  an  abundant  sanious  dischargre  from  the  wound. 
On  the  fourth  day  her  strength  was  greatly  re- 
duced, and  the  wound  had  almost  ceased  to  dis- 
charge, but  the  arm  was  very  much  swollen.  On 
the  fifth  day  she  died. 

Treatment  of  compound  fractures  of  the  elbow-joint. 
—  In  all  cases. of  this  accident,  the  arm  should  be 
kept  in  the  bent  position;  for  as  anchylosis,  in  a 
greater  or  lesser  degree,  is  the  certain  consequence, 


FRACTURES  OF  THE  ELBOW-JOINT. 


461 


k  is  attended  with  much  less  inconvenience  in  this 
p)sition  than  in  any  other.  If  the  bones  be  much 
comminuted,  and  the  wound  large,  all  the  detached 
portions  of  bone  should  be  removed;  but  in  old 
people,  wlien  much  injury  is  done,  there  is  often 
not  sufficient  strength  to  support  the  adhesive  pro- 
cess, and  amputation  should  be  recommended.  The 
edges  of  the  wound  should  be  kept  together  by 
placing  a  piece  of  lint,  dipped  in  blood,  over  them, 
supported  by  adhesive  plaster,  and  a  bandage^ 
lightly  applied,  wetted  with  spirits  of  wine  and 
water. 


STRUCTURE  OF  THE  WRIST-JOINT. 


Srucfure  of  the  joint ;  bones.  —  The  radius  and  the 
three  first  bones  of  the  carpus,  form  the  articular 
surfaces  of  the  wrist-joint;  the  radius  having  an 
oval  cavity  at  its  lower  extremity,  which  receives 
the  rounded  surfaces  of  the  scaphoid,  lunar,  and 
cuneiform  bones.  The  articular  cartilage  which 
covers  this  surface  of  the  radius  is,  at  its  inner  edge, 
extended  beneath  the  ulna,  so  as  to  exclude  that 
bone  from  the  general  cavity  of  the  wrist-joint. 
This  articular  cartilage  is  hollow,  both  above  and 
below  ;  and  at  its  lower  surface  it  rests  upon  the  os 
cuneiforme. 

Capsular  ligament.  —  A  capsular  ligament  passes 
from  the  edge  of  the  articular  cavity  of  the  radius, 
and  from  the  interarticular  cartilage  of  the  ulna,  to 
the  three  first  bones  of  the  carpus,  surrounding  a 
large  portion  of  the  scaphoid  and  lunar  bones,  and 
but  a  small  surface  of  the  cuneiforme. 

Ulna  joint. —  The  second  joint  at  this  part  is  that 
formed  between  the  radius  and  the  ulna.  On  the 
inner  side  of  the  lower  extremity  of  the  radius  is 
situated  a  hollow  articulatory  surface,  which  re- 
ceives an  articular  surface  on  the  outer  side  of  the 
ulna,  and  both  are  covered  by  an  articular  cartilage. 


STRUCTURE  OF  THE  WRIST-JOINT.  463 


At  the  lower  part  of  this  joint  is  placed  the  inter- 
articular  cartilage  of  the  ulna,  the  outer  edge  of 
which  is  joined  to  the  articular  cartilage  of  the  ra- 
dius, and  its  inner  edge  is  united  to  the  ulna  bj  liga- 
ment, which  sinks  into  a  cavity  formed  at  the  lower 
extremity  of  this  bone,  between  the  styloid  process 
of  the  ulna  and  its  rounded  extremity. 

Sacciform  ligament,  —  The  capsular  ligament, 
which  unites  the  ulna  to  the  radius,  is  called  the 
sacciform  ligament:  it  covers  the  articular  surfaces 
of  the  two  bones,  and  is  united  below  to  the  move- 
able cartilage  of  the  ulna.  This  joint  of  the  wrist 
is  formed  for  the  purpose  of  supporting  the  rotatory 
motion  of  the  radius  upon  the  ulna,  and  of  strongly 
uniting  one  bone  to  the  other. 

Radio-carpal ;  Ulna-carpal.  —  The  wrist  is 
strengthened  on  each  side  by  peculiar  ligaments : 
one  proceeds  from  the  styloid  process  of  the  radius, 
to  be  fixed  to  the  outer  edge  of  the  scaphoid  bone, 
which  is  ih(y  radio-carpnl  ligament ;  and  an  ulna-car- 
pal ligament  extends  from  the  styloid  process  of  the 
ulna,  to  the  os  cunelforme,  and  os  orblculare. 


DISLOCATIONS  OF  THE  WRISTJOINT. 


The  dislocations  of  this  joint  are  of  three  kinds  :  — 
First,  dislocation  of  both  bones. 
Secondly,  dislocation  of  the  radius  only* 
Thirdly,  dislocation  of  the  ulna. 

Mode  in  which  these  accidents  happen.  —  The  first 
accident,  namely,  the  dislocation  of  both  bones,  is 
not  of  very  frequent  occurrence  ;  but  when  it  does 
happen,  the  bones  are  thrown  cither  backwards  or 
forwards,  according  to  the  direction  in  which  the 
force  is  applied.  If  the  person  in  falling  puts  out 
his  hand  to  save  himself,  and  falls  upon  the  palm, 
a  dislocation  is  produced,  the  radius  and  ulna  are 
forced  forwards  upon  the  ligamentum  carpi  annulare, 
and  the  carpal  bones  are  thrown  backwards. 

Appearance,  —  The  appearances  of  this  disloca- 
tion are  these:  —  A  considerable  swelling  is  produc- 
ed by  the  radius  and  ulna,  on  the  fore  part  of  the 
wrist,  and  a  similar  protuberance  upon  the  back  of 
the  wrist  by  the  carpus,  with  a  depression  above  it ; 
the  hand  is  bent  back,  being  no  longer  in  the  line 
with  the  fore  arm. 


DISLOCATIONS  OF  THE   WRIST-JOINT.  465 


In  the  dislocation  of  the  radius  and  ulna  back- 
wards, the  person  falls  upon  the  back  of  the  hand, 
the  radius  and  ulna  are  thrown  upon  tiie  posterior 
part  of  the  carpus,  and  the  carpus  itself  is  forced 
under  the  flexor  tendons,  which  pass  behind  the  li- 
garaentum  carpi  annulare  ;  but  in  each  ol"  these  cases 
two  swellings  are  produced,  one  b>;  the  radius  and 
ulna,  and  the  other  by  the  bones  of  the  carpus,  ac- 
cording to  the  direction  in  which  thej  are  thrown  : 
and  these  become  the  diagnostic  signs  of  the  acci- 
dent. 

Sprains.  —  Severe  falls  upon  the  palm  of  the  hand 
will  produce  sprains  of  the  tendons  on  the  fore  part 
of  the  wrist,  and  occasion  a  very  considerable  swell-  « 
ing  of  the  flexor  tendons,  opposite  the  wrist-joint. 
This  accident  assumes  the  appearance  of  dislocation, 
but  may  alw^ays  be  distinguished  from  it  by  the  exist- 
ence of  one  swelling  only,  which  does  not  appear 
immediately  after  the  injury  is  received,  but  suc- 
ceeds it  gradually.  And  further,  if  the  surgeon  be 
called  directly  after  the  dislocation  has  happened, 
there  is  then  a  great  flexibility  of  the  hand,  as  well 
as  distortion,  and  the  extremities  of  the  radius  and 
ulna  on  one  side,  and  of  the  carpal  bones  on  the 
other,  are  easily  detected. 

Reduction,  —  The  reduction  of  this  dislocation,  in 
whatever  form  it  may  have  occurred,  is  by  no  means 
difficult.  The  surgeon  grasps  the  patient's  hand 
with  his  right  hand,  supporting  the  fore  arm  with 
his  left,  whilst  an  assistant  places  his  hands  around 
the  upper  arm,  just  above  the  elbow  ;  they  then 
pull  in  different  directions,  and  the  bones  become 
easily  replaced.  The  reduction  is  in  both  cases  the 
same,  for  the  muscles  draw  the  bones  towards  their 
natural  position  as  soon  as  they  are  separated  from 
the  carpus  by  extension. 

When  the  hand  recovers  its  natural  situation,  a 
59 


466  DISLOCATIONS  OF  THE  WRIST-JOINT. 


roller,  wetted  in  spirits  of  wine  and  water,  is  to  be 
lightly  applied  around  the  wrist,  and  the  whole  is 
to  be  supported  by  splints  placed  before  and  behind 
the  fore  arm,  reaching  as  far  as  the  extremities  of 
the  metacarpal  bones,  for  the  more  perfect  security 
of  the  limb. 


DISLOCATION  OF  THE  RADIUS  AT  THE  WRIST. 

Diagnostic  marks  of  this  accident,  —  This  bone  is 
sometimes  separately  thrown  upon  the  fore  part  of 
the  carpus,  and  lodged  upon  the  scaphoid  bone  and 
the  OS  trapezium.  The  outer  side  of  the  hand  isj 
in  this  case,  twisted  backwards,  and  the  inner  for- 
wards: the  extremity  of  the  radius  can  be  felt  and 
seen,  forming  a  protuberance  on  the  fore  part  of  the 
wrist.  The  styloid  process  of  the  radius  is  no  longer 
situated  opposite  to  the  os  trapezium. 

Cause  of  the  accident.— This  accident  usually  hap- 
pens from  a  fall  when  the  hand  is  bent  back;  and  I 
have  also  known  it  arise  from  a  fall  upon  the  hand, 
by  which  the  condyles  of  the  os  humeri  were  bro- 
ken obliquely,  and  the  radius  dislocated  at  the  wrist, 
being  thrown  upon  the  fore  part  of  the  scaphoid 
bone,  where  it  could  be  distinctly  felt:  this  was  the 
case  of  the  lad  whom  I  mentioned  when  speaking 
of  fractures  of  the  os  humeri ;  his  hand  was  hang- 
ing backwards,  and  he  felt  great  pain  upon  its  being 
moved. 

The  extension  necessary  to  reduce  a  dislocation 
of  the  radius,  and  the  treatment  which  it  demands, 
are  the  same  which  are  required  for  the  luxation  of 
both  bones;  and  there  is  no  difficulty  in  the  opera- 
tion, the  hand  being  extended  whilst  the  fore  arm  is 
fixed. 


DISLOCATIONS  OF  THE  WRIST-JOINT, 


467 


DISLOCATION   OF  THE  ULNA. 

As  this  bone  does  not  form  a  part  of  the  wrist- 
joint,  but  is  received  into  a  capsular  ligament  of  its 
own,  and  is  separated  from  the  wrist  by  a  moveable 
cartilage,  it  is  more  frequently  dislocated, separately, 
than  the  radius. 

Symptoms. —  When  this  accident  occurs,  the  sac- 
ciform ligament  is  torn  through,  and  the  bone  gener- 
ally projects  backwards,  without  any  accompanying 
fracture  of  the  radius.  It  rises  and  forms  a  protu- 
berance at  the  back  of  the  wrist;  and  although  it 
is  easily  pressed  down  into  its  natural  position,  yet 
so  soon  as  the  pressure  is  removed  the  deformity  re- 
turns, as  the  lacerated  ligament  has  no  longer  the 
power  to  retain  it  in  its  place. 

Diagnostic  marks.  —  The  diagnostic  marks  of  the 
injury  are  the  projection  of  the  ulna,  much  above 
the  level  of  the  os  cunelformc,  and  altered  position 
of  the  styloid  process,  which  is  no  longer  in  a  line 
with  the  metacarpal  bone  of  the  little  finger. 

Mode  of  reduction,  —  The  reduction  is  accom- 
plished by  pressure  of  the  bone  forwards,  which 
brings  the  ulna  into  its  natural  articular  cavity  by 
the  side  of  the  radius  ;  and  to  retain  it  in  this  situa- 
tion, splints  must  be  placed  along  the  fore  arm,  in  a 
line  with  the  back  and  palm  of  the  hand;  the  splints 
should  be  padded  throughout;  but  upon  the  ex- 
tremity of  the  ulna  a  compress  of  leather  should  be 
placed,  to  keep  it  in  a  line  with  the  radius;  a  roller 
should  then  be  applied  over  the  splints  to  confine 
them  with  sufficient  firmness. 


463  I>ISLOCATION&  OF  THE  WRIST-JOINT. 


COMPOUND^  DISLOCATION  OF  THE  WRIST,  ULNA  PROJECTED, 
AND  FRACTURE  OF   THE  RADIUS. 

June  2\st,  1818. 
John  Winter  fell  from  a  ladder  on  his  hand  and 
knee  ;  the  hand  was  bent  back,  and  the  ulna  pro- 
truded at  the  inner  part  of  the  wrist.  Mr  Steel,  of 
Berkhampstead,  attended  ;  the  bone  was  reduced,  a 
roller  was  put  around  the  wrist,  and  the  wound 
healed  very  soon  by  adhesion.  In  seven  weeks  he 
was  well,  excepting  that  a  slight  swelling  of  the  ten- 
dons renaained  for  a  few  weeks  longer. 


SIMPLE  FRACTURE   OF  THE   RADIUS,  AND  DISLOCATION 
OF   THE  ULNA. 

*/?  Jrequent  accident,  —  The  radius  is  frequently 
broken,  and  the  ulna  at  the  same  time  dislocated ; 
the  fracture  usually  happens  one  inch  above  the 
articulation.  If  it  occurs  in  a  very  oblique  direc- 
tion, so  great  a  displacement  of  the  radius  ensues, 
that  dislocation  of  the  ulna  forwards  is  also  pro- 
duced. 

Dissection.-— I  have  given  a  plate  of  this  accident 
from  a  preparation  of  it  in  the  Museum  at  St  Tho- 
mas's Hospital.  (See  Plate,)  The  lower  end  of 
the  radius  is  seen  in  its  natural  situation,  articulated 
with  the  carpal  bones.  An  inch  above  the  liga- 
mentum  annulare  carpi,  the  broken  extremity  of  the 
radius  is  seen  projecting  under  the  flexor  tendons  of 
the  wrist,  which  have  been  removed  to  show  its 
situation ;  the  ulna  is  dislocated  forwards,  and  rests 
upon  the  os  orbiculare. 


PSLOCATIONS  OF  THE  WRIST-JOINT.  460 


Diagnostic  marks  of  this  accident,  —  The  signs  of 
this  injury  are,  that  the  hand  is  thrown  back  upon 
the  fore  arm,  so  as  at  first  sight  to  exhibit  the 
appearance  of  a  dislocation  of  the  hand  backwards ; 
and  a  projection  of  the  ulna  is  felt  under  the  tendon 
of  the  flexor  carpi  uhiaris  muscle,  just  above  the  os 
orbiculare ;  and  thirdly,  the  fractured  extremity  of 
the  radius  is  easily  detected,  under  the  flexor  ten- 
dons of  the  hand.  I  have  seen  this  accident  fre- 
quently, and  at  first  did  not  exactly  understand  the 
nature  of  the  injury  ;  indeed,  dissection  alone  taught 
me  its  real  character. 

Mode  of  reduction,  and  its  difficulties,  —  A  very 
powerful  extension  is  required  to  bring  the  broken 
ends  of  the  radius  into  apposition,  and  great  difficulty 
exists  in  confining  them  when  this  is  effected.  The 
hand  is  to  be  extended  by  the  surgeon,  and  the  fore 
and  upper  arm  are  to  be  drawn  back  by  an  assistant ; 
then  a  cushion  is  to  be  placed  upon  the  inner  part  of 
the  wrist,  and  another  to  the  back  of  the  hand, 
firmly  bound  down  by  a  roller,  for  the  purpose  of 
keeping  the  ulna  and  broken  end  of  the  radius  in 
situ ;  a  splint,  well  padded,  is  then  lo  be  applied  to 
the  back  part  and  inner  side  of  the  fore  arm,  which 
is  to  extend  to  the  extremities  of  the  metacarpal 
bones  ;  these  splints  are  to  be  confined  by  a  roller, 
reaching  from  the  upper  part  of  the  fore  arm  to  the 
wrist,  and  no  farther.  The  arm  should  be  then 
placed  in  a  sling :  this  position  is  to  be  preserved 
for  three  weeks  in  young  persons,  and  for  four  or 
five  in  the  aged,  before  passive  motion  be  attempted. 
The  recovery  in  these  cases  is  slow,  and  six  months 
will  sometimes  elapse  before  motion  of  the  fingers  is 
completely  restored.    (See  Plate,') 


470  DISLOCATIONS  OF  THE  WRIST-JOINT. 


FRACTURE  OF  THE  LOWER  END   OF  THE  RADIUS 
WITHOUT  DISLOCATION   OF  THE  ULNA. 

Symptoms  of  this  accident ;  treatment.  —  This  frac- 
ture generally  happens  about  an  inch  above  the  sty- 
loid process.  The  cure  is  difficult,  (he  lower  ex- 
tremity of  the  broken  bone  being  drawn  by  the  ac- 
tion of  the  pronator  quadratus  amongst  the  flexor 
tendons,  where  it  may  be  distinctly  felt :  in  this  situ- 
ation it  interferes  very  considerably  with  the  mo- 
tions of  the  fingers,  by  confining  the  action  of  the 
flexor  profundus  perforans.  Mr  Cline,  in  his  lec- 
tures on  this  subject,  used,  nearly  in  these  terms,  to 
recommend  the  following  treatment: — 'When  a 
fracture  of  the  radius  happens  just  above  the  wrist- 
joint,  you  must  be  very  careful  in  your  treatment  of 
it,  to  prevent  the  injury  from  leading  to  the  perma- 
nent loss  of  the  use  of  the  fingers  ;  for  so  soon  as  the 
injury  has  happened,  the  pronator  quadratus  muscle 
draws  the  fractured  end  of  the  bone  obliquely  across 
the  fore  arm,  amidst  the  flexor  tendons  ;  your  object, 
therefore,  in  the  treatment  of  this  accident  is,  to 
prevent  the  action  of  the  pronator  from  producing 
that  eflfect ;  and  the  mode  of  treatment  which  you 
are  to  adopt  is,  to  make  the  hand,  by  its  weight, 
oppose  the  action  of  that  muscle.  For  this  purpose, 
when  the  bone  has  been  placed  in  its  right  position, 
by  drawing  the  hand  in  a  line  with  the  fore  arm, 
apply  a  roller  around  the  fore  arm  to  the  wrist; 
then  a  splint  upon  the  fore  and  back  part  of  the 
arm  to  reach  to  the  palm  and  back  of  the  hand,  so 
as  to  preserve  it  in  a  half  supine  position ;  and  con- 
fine the  splints  by  means  of  a  roller,  which  should 
reach  only  to  the  wrist.  The  arm  is  then  to  be 
placed  in  a  sling,  which  is  also  to  support  it  no  fur- 
ther than  to  the  wrist.    Thus  the  hand,  being  allow- 


DISLOCATIONS  OF    THE  WRIST-JOINT. 


471 


ed  to  han^  between  tlie  ends  of  the  splints,  draws 
tlie  end  of  the  radius,  so  as  to  maintain  a  constant 
extension  upon  if,  opposing  the  action  of  the  prona- 
tor quadratus  muscle,  and  keeping  the  broken  end 
of  the  bone  constantly  in  its  place.' 


COMPOUND  DISLOCATION   OF  THE  ULNA,   WITH  FRACTURE 
OF  THE  RADIUS. 

Often  a  very  serious  accident.  —  This  is  a  very  se- 
rious accident  when  the  radius  is  much  comminuted 
(see  Plate)  ;  but  recovery  proceeds  very  well,  when 
the  radius  is  broken  without  being  shattered.  I  saw 
a  case  of  this  injury  in  Hertfordshire,  in  which  the 
man  met  with  the  accident  by  falling  upon  the  back 
of  his  hand,  and  the  ulna  protruded  an  inch  and  a 
half  through  the  integuments.  The  bone  was  imme- 
diately reduced  and  bandaged ;  the  wound  healed 
by  the  adhesive  process,  and  the  man  recovered  the 
perfect  use  of  his  limb. 

Case.  —  Susannah  Griffith,  a  woman  from  Rother- 
hithe  Poorhouse,  aged  seventy-two,  was  admitted 
into  Guy's  Hospital,  on  the  10th  of  April,  1822. 
Whilst  walking  on  the  pavement,  her  foot  had  acci- 
dentally slipped,  and  she  fell  with  her  right  hand 
under  her,  in  such  a  manner,  that  the  palmar  surface 
was  forcibly  bent  against  the  inner  side  of  the  fore 
arm;  the  carpal  extremity  of  the  ulna  was,  conse- 
quently, thrown  violently  outwards  through  the  in- 
teguments, and  the  lower  end  of  the  radius  was  ob- 
liquely fractured. 

The  parts  were  reduced,  and  the  edges  of  the 
wound  brought  as  closely  into  contact  as  the  lacerat- 
ed condition  of  it  would  admit ;  a  pledget  of  lint, 


DISLOCATIONS  OF  THE  WRIST-JOINT. 


dipped  in  blood,  was  applied  to  the  part,  and  a  band 
age  over  it. 

On  the  third  day  the  arm  became  tumefied  and 
inflamed,  and  poultices  were  apphed.  By  the  21st 
of  May  the  fracture  of  the  radius  had  united,  and 
the  patient  recovered  the  use  of  the  thumb  and  two 
first  fingers ;  the  whole  of  the  articular  cartilage 
had  come  off  in  the  form  of  black  sloughs,  intermix- 
ed with  spiculoe  of  the  adjacent  bone,  and  the  gra- 
nulations were  so  prominent,  as  to  lead  to  the  appli- 
cation of  adhesive  straps  :  the  healing  process,  how- 
ever, was  greatly  retarded  by  a  frequent  displace-* 
ment  of  the  extremity  of  the  ulna,  owing  to  the 
constitutional  irritability  of  the  patient,  and  to  the 
cedematous  state  of  the  arm,  which  did  not  allow 
the  bandages  to  be  applied  with  the  tightness  requi- 
site for  its  due  confinement. 

On  the  18th  of  June,  the  wound  was  nearly  heal- 
ed; but  still  a  small  portion  of  the  end  of  the  ulna 
will  exfoliate,  and  she  applies  the  lotion  acidi  nitrici, 
to  hasten  its  exfoliation. 

Peploe  Cartwright, 

j^Kgust  Idth,  1822,  Dresser,  Guy^s  Hospital. 

Case.  —  A  man  was  admitted  into  St  Thomas's 
Hospital,  under  the  care  of  Mr  Chandler.  I  now 
forget  in  what  manner  the  accident  had  happened, 
but  the  ulna  projected  through  the  integuments  at 
the  back  of  the  carpus:  and  a  compound  fracture 
of  the  radius,  with  great  comminution  of  the  bone, 
was  produced.  The  ulna  was  at  first  replaced,  but 
immediately  resumed  its  dislocated  position  on  the 
back  of  the  wrist,  although  it  did  not  again  protrude 
through  the  skin.  The  hand  and  fore  arm  were 
placed  in  a  poultice,  and  were  ordered  to  be  foment- 
ed twice  a  day.    A  copious  suppuration  ensued,  at- 


DISLOCATIONS   OF  THE   WRiST-JpINT.  473 


tended  with  violent  constitutional  irritation ;  and  Mr 
Chandler,  in  order  to  save  the  patient's  life,  after  a 
lapse  of  five  weeks,  amputated  the  limb. 

Dissection.  —  On  dissection,  I  found  the  ulna  dis- 
located backwards,  and  its  extremity  just  drawn  with- 
in the  opening  of  the  integuments,  through  which  it 
had  protruded.  The  radius  was  broken  into  several 
pieces,  some  of  which  being  loose,  were  necessarily 
a  great  source  of  irritation  ;  the  tendons  and  muscles 
were  some  of  them  lacerated,  as  the  extensor  carpi 
radialis  longior,  and  the  extensors  of  the  thumb. 

Treatment.  —  In  a  similar  case  it  would  be  proper, 
when  loose  pieces  of  bone  can  be  felt  at  the  extre- 
mity of  the  radius,  that  the  wound  should  be  en- 
larged for  their  removal ;  and  instead  of  fomenta- 
tion£^  and  poultices,  a  quantity  of  lint,  dipped  in  the 
patient's  blood,  should  be  applied  round  the  wrist, 
lightly  bound  with  a  roller.  The  arm  should  be 
supported  upon  a  splint,  so  as  to  be  kept  perfectly 
free  from  motion;  evaporating  lotions  .should  be  ap- 
plied ;  and  the  limb  should  not  be  disturbed,  unless 
the  patient  has  symptoms  of  a  suppurative  process, 
when  a  small  opening  should  be  made  in  the  bandage 
to  allow  of  the  escape  of  pus,  but  still  the  bandages 
should  be  suffered  to  remain.  The  patient  should  be 
bled  from  the  arm  if  the  inflammation  and  constitution- 
al irritation  be  considerable,  and  under  these  circum- 
stances leeches  should  be  occasionally  applied.  The 
bowels  should  be  kept  gently  open,  but  all  active 
purging  avoided. 


DISLOCATIONS  OF  THE  CARPAL  BONES. 


Carpal  joint.  —  The  eight  bones  of  the  carpus 
are  joined  to  each  other  by  short  ligaments,  which 
pass  from  bone  to  bone,  allowing  but  a  very  slight 
degree  of  motion  of  one  bone  upon  another;  but 
besides  this  mode  of  articulation,  there  is  a  transverse 
joint  between  the  first  and  second  row  of  carpal 
bones,  forming  a  complete  ball  and  socket.  The 
ball  is  produced  by  the  rounded  extremities  of  the 
OS  magnum  and  os  cuneiforme  :  the  cup,  by  the  sca- 
phoid, lunar,  and  cuneiform  bones.  A  ligament 
passes  from  one  row  of  bones  to  the  other,  including 
this  articulation. 

The  dislocation  of  a  carpal  bone  is  but  of  rare 
occurrence  ;  the  following  is  an  example  of  the  ac- 
cident. 

Case,  —  Mary  Nichols,  aged  sixty,  slipped  down, 
and,  trying  to  save  herself,  fell  upon  the  back  of 
her  hand  and  fractured  the  radius  obliquely  outwards, 
through  the  lower  articulating  surface.  The  frac- 
tured portion,  with  the  os  scaphoides,  was  thrown 


DISLOCATIONS  OF  THE  CARPAL  BONES. 


475 


backwards  upon  the  carpus.  The  wrist  was  slightly 
bent,  and  there  was  an  evident  projection  at  the 
back  of  the  carpus.  The  fingers  could  be  com- 
pletely extended,  but  only  semiflexed.  A  crepitus 
might  be  distinctly  felt,  either  by  moving  the  hand, 
or  the  styloid  process  of  the  radius  backwards  or 
forwards.  By  slight  extension,  and  steady  pressure 
upon  the  displaced  part,  the  fracture  was  easily  re- 
duced. There  was  much  extravasation  and  pain  5 
six  leeches  were  applied,  afterwards  evaporating  lo- 
tions, and  two  long  splints  ;  and  as  soon  as  the  swell- 
ing had  in  some  measure  subsided,  strips  of  soap 
plaster.  At  the  end  of  six  weeks  the  fracture  was 
firmly  united,  but  the  motions  of  the  wrist  are  still 
imperfect,  and  she  cannot  grasp  any  thing. 

F.  R.  Elkington, 
August  \3thy  1822.  Dresser,  Guyh  Hospital 

Ganglia  are  sometimes  mistaken  for  this  accident; 
but  in  such  cases  a  smart  blow  with  a  book  will  dis- 
perse the  swelling,  and  dispel  the  cloud  of  doubt 
which  enveloped  the  mind  of  the  surgeon. 

Relaxation  of  the  carpal  joint.  —  The  os  magnum 
and  the  cuneiform  bones,  from  relaxation  of  their 
ligaments,  are  occasionally  thrown  somewhat  out  of 
their  natural  situation,  so  that  when  the  hand  is  bent, 
they  form  protuberances  at  the  back  of  the  wrist. 
This  state  is  productive  of  so  great  a  degree  of 
weakness,  as  to  render  the  hand  useless  unless  the 
wrist  be  supported.  1  was  consulted  by  a  young 
lady,  a  patient  of  Mr  Gumming,  of  Chelsea,  who  had 
such  a  projection  of  the  os  magnum,  that  she  was, 
in  consequence,  obliged  to  give  up  her  music  and 
other  accomplishments,  on  account  of  the  attendant 
weakness  ;  for  when  she  wished  to. use  her  hand, 
she  was  compelled  to  wear  two  short  splints,  which 


476 


DISLOCATIONS  OP  THE  CARPAL  BONES. 


were  adjusted  to  the  wrist,  and  bound  upon  the  back 
and  fore  part  of  the  hand  and  fore  arm.  Another 
lady,  who  had  a  weakened  state  of  limb,  arising 
from  a  similar  cause,  wore,  for  the  purpose  of  giving 
it  strength,  a  strong  bracelet  of  steel  chain,  clasped 
very  tightly  around  the  wrist.  But  the  supports 
generally  directed  to  be  worn  in  these  cases  are 
straps  of  adhesive  plaster,  and  a  bandage  over  the 
wrist  to  confine  and  strengthen  it.  The  effusion  of 
cold  water  upon  the  hand  from  a  considerable  height 
is  also  employed,  and  the  part  is  afterwards  rubbed 
with  a  coarse  towel,  to  give  vigour  to  the  circula- 
tion, and  strength  to  the  joints. 


COMPOUND  DISLOCATION   OF  THE  CARPAL  BONES. 

These  accidents  are  of  frequent  occurrence,  and 
they  are  generally  caused  by  guns  bursting  in  the 
hand ;  portions  of  the  instrument  being  forced 
through  the  carpus,  and  between  the  metacarpal 
bones. 

Recovery.  —  In  these  cases  a  carpal  bone  may  be 
removed  by  dissection,  and  the  patient  may  recover; 
not  only  saving  his  hand,  but,  in  a  considerable  de- 
gree, preserving  its  motions;  of  which  the  following 
is  an  example. 

Case,  —  Richard  Mitchell,  aged  twenty-two,  was 
admitted  into  Guy's  Hospital,  under  Mr  Forster,  on 
the  17th  of  October,  1822,  for  an  extensive  wound 
in  the  wrist-joint,  inflicted  by  wliat  is  called  a  wool- 
comber's  devil.  On  examination  it  was  found  that 
the  wound  extended  through  two-thirds  of  the  cir- 
cumference of  the  joint,  and  was  attended  with  a 
great  deal  of  contusion  ;  the  scaphoid  bone  projected 
at  the  back  part,  being  attached  only  on  the  side 


DISLOCATIONS  OP  THE  CARPAL  BONES.  477 


towards  the  joint ;  in  consequence  of  this,  the  joints 
into  which  it  enters  were  laid  open  ;  the  extensor 
tendons  of  the  thumb,  and  of  the  middle  and  fore 
fingers,  were  torn  through;  the  radial  artery  was 
also  torn,  but  did  not  afford  any  considerable  hae- 
morrhage. The  scaphoid  bone  was  removed  with 
a  scalpel  ;  the  edges  of  the  wound  were  brought 
together  by  sutures,  and  lint,  dipped  in  blood,  was 
applied  to  it  and  confined  by  adhesive  straps;  the 
fore  arm  and  hand  were  laid  on  a  splint,  so  as  to 
keep  the  joint  perfectly  at  rest ;  the  patient  was 
bled  to  twelve  ounces,  and  an  evaporating  lotion  or- 
dered. In  two  or  three  days  the  dressings  were 
removed,  in  consequence  of  the  pain,  when  a  good 
deal  of  surrounding  inflammation  was  found,  and  in 
one  spot  a  slough  ;  the  sutures  were  removed,  and 
a  poultice  ordered  ;  two  or  three  days  after  this, 
abscesses  formed  along  the  thecae  of 'the  tendons, 
which  were  opened.  The  slough  quickly  separated, 
and  the  inflammation  subsided,  as  the  suppurative 
process  became  established.  In  two  or  three  weeks, 
the  wound  was  so  well  filled,  as  to  allow  the  applica- 
tion of  adhesive  straps,  under  which  treatment  it 
gradually  healed.  The  only  constitutional  symptoms 
which  occurred  during  the  progress  of  the  case 
were  those  of  common  irritative  fever,  which  were 
relieved  by  the  exhibition  of  antimony,  with  opium 
and  the  liq.  ammon.  acet.  with  the  tinct.  opii.  and 
the  use  of  mild  cathartics.  A  pulmonic  affection, 
which  threatened  phthisis,  was  also  relieved  by  the 
use  of  leeches  and  diaphoretics,  which,  however, 
considerably  retarded  his  recovery. 

Whilst  his  wound  was  in  the  progress  of  'healing, 
passive  motion  was  early  and  regularly  practised  : 
and  after  it  had  healed,  friction,  with  the  soap  lini- 
ment: but  he  hftd  only  a  limited  power  of  moving 
his  fingers  when  he  left  the  hospital. 


478  DISLOCATIONS  OP  THE  CARPAL  BONES. 


All  the  intelligence  I  can  now  gain  of  him  is,  that 
he  has  lately  gone  to  work,  under  the  hope  that  the 
constant  habit  of  grasping  bodies  (which  indeed  I 
strenuously  recommended  to  him  previously),  will 
restore  the  motion  of  his  fingers. 

Charles  Fagg, 

Aug,  '\2th,  1822.  Dresser,  Gwifs  Hospital. 

When  only  one  or  two  of  the  carpal  bones  are 
displaced  by  guns  bursting  in  the  hand,  they  may 
be  dissected  away;  but  if  more  considerable  injury 
be  done,  amputation  will  be  necessary. 


DISLOCATIONS  OF  THE  METACARPAL 
BONES. 


Arrfputation  often  necessary.  —  These  bones  are  so 
firmly  articulated  with  the  bones  of  the  carpus,  that 
I  have  never  seen  them  dislocated  but  by  the  burst- 
ing of  guns,  or  by  the  passage  of  heavy  laden  car- 
riages over  the  hand;  and  in  each  of  these  eases 
there  is  generally  so  much  injury  produced,  as  to 
render  amputation  necessary.  In  the  former  of 
these  accidents,  a  bone,  and  sometimes  two,  are  ca- 
pable of  being  removed;  and  if  it  be  necessary  to 
amputate  the  middle  and  ring  finger,  the  fore  and 
little  finger  may  be  brought  so  nicely  together,  and 
secured  in  such  exact  adhesion,  as  to  produce  little 
deformity. 

Case.  —  I  was  called  by  Mr  Hood,  surgeon  at 
Vauxhall,  to  a  Mr  Waddle,  of  Bow-lane,  Cheapside, 
who,  whilst  shooting,  had  his  gun  burst,  and  his  hand 
lacerated  by  a  portion  of  the  barrel  passing  through 
its  centre.  The  metacarpal  bones  of  the  middle  and 
ring  fingers  were  fractured,  and  also  much  commi- 
nuted by  the  violence  of  the  injury,  but  the  integu- 


480       DISLOCATIONS   OF  THE  METACARPAL  BONES. 


ments  were  only  lacerated,  and  not  completely  re- 
moved. I  dissected  out  the  two  fingers,  with  the 
metacarpal  bones  which  supported  them,  and  brought 
the  edges  of  the  skin  together  by  suture,  approxi- 
mating the  fore  and  little  finger,  and  applying  a 
roller,  so  as  to  bind  them  together  ;  the  parts  united 
perfectly,  and  the  maimed  hand  was  afterwards  ex- 
tremely useful  to  him  :  the  case,  indeed,  is  highly 
worthy  of  inspection. 

Case.  —  A  boy  of  twelve  years  of  age  was  brought 
into  Guy's  Hospital,  who,  by  the  bursting  of  a  gun, 
had  his  thumb  anJ  all  the  fingers,  excepting  the  fore 
finger,  blown  to  pieces;  the  whole  hand  was  exceed- 
ingly shattered,  and  the  metacarpal  bones  were  se- 
parated from  the  carpus.  Upon  examination  of  the 
hand,  I  found  that  the  tendon  of  the  fore  finger  was 
uninjured,  so  that  its  use  remained  perfect ;  and  as 
the  integument  could  be  still  saved,  so  as  to  cover 
its  metacarpal  bone,  I  dissected  out  the  trapezium 
(the  thumb  had  been  entirely  carried  away  by  the 
concussion),  and  the  metacarpal  bones  of  all  the  fin- 
gers, excepting  that  of  the  fore  finger,  which  was 
afterwards  of  the  greatest  use  to  him.  1  kept  him 
for  some  time  at  the.  hospital,  to  show  to  the  stu- 
dents the  restorative  powers  of  nature,  and  the  utility 
of  this  finger,  saved  out  of  the  wreck  of  his  hand ; 
he  used  it  as  a  hook  with  the  greatest  facility. 


FRACTURE  OF  THE  HEAD  OF  THE  METACARPAL  BONE. 

Fracture,  —  The  extremity  of  the  metacarpal 
bone  towards  the  fingers,  which  is  called  its  head,  is 
sometimes  broken  off,  and  it  gives  the  appearance  of 
dislocation  of  the  finger,  as  the  head  of  the  bone 
sinks  towards  the  palm  of  the  hand.    In  the  treat- 


DISLOCATIONS  OF  THE  METACARPAL  BONES.  481 

ment  of  this  case,  a  large  ball  is  to  placed  in  the 
hand,  grasped  by  it,  and  bound  over  it  by  a  roller; 
and  thus  the  depressed  extremity  of  the  bone  is  raised 
to  its  natural  situation. 


6t 


DISLOCATIOxNS  OF  THE  FINGERS  AND 

TOES. 


Structure.  — The  phalanges  of  the  fingers  and  of  the 
toes  are  united  bjr  capsular  ligaments  to  the  metacar- 
pal and  metatarsal  bones,  and  to  each  other;  and  their 
union  is  further  strengthened  bj  lateral  ligaments, 
proceeding  from  the  side  of  one  phalanx  to  the  other. 
Posteriorly,  they  are  defended  by  the  tendon  of  the 
extensor  muscle  of  the  fingers;  and  anteriorly,  by 
the  thecse  and  flexor  tendons.  Dislocation  of  the 
phalanges,  therefore,  is  but  rare;  but  Avhen  this  ac- 
cident does  occur,  it  more  frequently  happens  between 
the  first  and  second  phalanges  than  between  the 
second  and  third. 

In  the  twenty-eighth  plate  this  dislocation  will  be 
seen;  the  second  phalanx  being  thrown' forwards 
towards  the  ffiecae,  and  the  first  backwards.  I  could 
not  learn  if  the  ligaments  had  been  torn,' as  the  dis- 
location had  existed  for  a  length  of  time,  and  the 
ligament,  if  it  had  ever  been  lacerated,  was  then 
united ;  the  extensor  tendon  was  very  much  stretched 
over  the  end  of  the  first  phalanx. 


DISLOCATIONS   OF  THE  FINGERS  AND  TOES.  483 

Diagnostic  marks  of  this  accident.  —  This  accident 
may  be  readily  distinguished  by  the  projection  of  the 
first  phalanx  backwards,  while  the  head  of  the  se- 
cond may  be,  although  less  distinctly,  felt  under  the 
thecae. 

Reduction,  —  The  reduction  may  be  effected  by 
making  extension  with  a  slight  inclination  forwards 
to  relax  the  flexor  muscles.  If  the  bone  has  not 
been  dislocated  many  hours,  it  is  easily  reduced  ;  but 
if  neglected  at  first,  this  can  only  be  accomplished 
by  a  long  continued  extension,  very  steadily  applied. 
1  have  seen  too  much  mischief  arise  from  injury  to 
the  tendons  and  ligaments  of  these  joints  ever  to 
recommend  the  division  of  them  (which  some  have 
advised)  to  facilitate  reduction,  when  extension  will 
not  succeed.  The  observations  which  I  have  made 
respecting  the  dislocation  of  the  fingers,  also  apply 
to  the  toes;  of  which,  however,  the  dislocations  are 
more  difficult  to  reduce,  from  their  greater  shortness, 
and  the  less  pliability  of  the  joints. 


DISLOCATION  FROM  CONTRACTION  OF  THE  TENDON. 

Contraction  of  tendon,  —  A  toe  or  finger  is  some- 
times gradually  thrown  out  of  its  natural  direction 
by  a  contraction  of  the  flexor  tendon  and  thecse,  and 
the  first  and  second  phalanges  are  consequently 
drawn  up  and  projected  against  the  shoe,  so  as  to 
prevent  the  patient  from  being  able  to  take  his 
usual  exercise. 

Amputation  required.  —  I  have  frequently  seen 
young  ladies  subject  to  this  inconvenience  in  the 
toe,  and  attribute  it  to  the  tightness  of  their  shoes  ; 
it  appears  an  extremely  harsh  measure  on  the  part 
of  the  surgeon  to  amputate  a  toe  under  such  circura- 


« 


484       DISLOCATIONS  OF  THE  FINGERS  AND  TOES. 


stances,  yet  it  is  sometimes  absolutely  necessary,  as 
the  contraction  deprives  the  person  of  exercise,  and 
of  many  of  the  enjoyments  of  life.  In  the  first  per- 
son whom  I  saw  w^ith  this  state  of  the  toe  \  refused 
to  amputate,  fearful  of  tetanus  being  produced  by 
the  operation;  but  the  lady  went  to  another  sur- 
geon, who  complied  with  her  request,  and  she  did 
very  well.  In  consequence  of  the  perfect  recovery 
of  this  lady,  and  the  comfort  which  she  derived 
from  the  loss  of  the  annoyance,  I  was  induced,  at 
the  request,  of  Mr  Toulmin,  of  Hackney,  to  remove 
one  of  the  toes  from  a  patient  of  his,  which  was 
constantly  irritated  by  the  pressure  of  her  shoe  in 
walking,  and  prevented  her  from  taking  the  exer- 
cise necessary  to  the  preservation  of  her  health; 
she  did  very  well,  perfectly  recovering  the  use  of 
her  foot. 

Contraction  of  fingers,  8{c.  — The  fingers  are  some- 
times contracted  in  a  similar  manner  by  a  chronic 
inflammation  of  the  thecas  and  aponeurosis  of  the 
palm  of  the  hand,  from  excessive  motion  of  the 
hand,  in  the  use  of  the  hammer,  the  oar,  ploughing, 
etc.  etc.  When  the  thecae  are  contracted,  nothing 
should  be  attempted  for  the  patient's  relief,  as  no 
operation  or  other  means  will  succeed  ;  but  when 
the  aponeurosis  is  the  cause  of  the  contraction,  and 
the  contracted  band  is  narrow,  it  may  with  advantage 
be  divided  by  a  pointed  bistoury,  introduced  through 
a  very  small  wound  in  the  integument.  The  finger 
is  then  extended,  and  a  splint  is  applied  to  preserve 
it  in  the  straight  position. 

Some  time  since,  my  nephew,  Mr  Bransby  Cooper, 
who  was  transacting  my  business  during  my  absence 
from  town,  performed  this  operation  for  a  Lincoln- 
shire farmer,  who,  by  this  impediment,  had  been  pre- 
vented following  his  avocations ;  and  he  perfectly 
recovered  the  use  of  his  foot. 


DISLOCATIONS  OF  THE   FINGERS  AND  TOES.  485 


DISLOCATION  OF  THE  THUMB. 

These  accidents  are  very  difficult  to  reduce,  on 
account  of  the  numerous  strong  muscles  which  are 
inserted  into  the  part. 

Structure,  —  The  thumb  consists  of  three  bones  : 
—  its  metacarpal  bone,  and  two.  phalanges.  The 
metacarpal  bone  of  the  thumb  is  articulated  with 
the  OS  trapezium  by  means  of  a  double  pulley;  that 
of  the  4rapezium  directing  the  thumb  towards  the 
palm  of  the  hand,  and  that  of  the  metacarpal  bone 
direcling  it  laterally.  The  metacarpal  bone  is  con- 
nected with  the  trapezium  by  a  capsular  ligament, 
and  a  very  strong  ligament  joins  the  first  phalanx  to 
the  palmar  part  of  the  trapezium,  at  its  lower  ex- 
tremity. The  metacarpal  bone  forms  a  rounded 
pojecting  articulatory  surface,  upon  which  the  hol- 
low of  the  first  phalanx  rests,  both  being  surround- 
ed by  a  capsular  ligament,  arid  strengthened  by  two 
strong  lateral  ligaments.  There  are  eight  muscles 
inserted  into  the  thumb:  two  into  the  metacarpal 
bone,  as  the  extensor  and  flexor  ossis  metacarpi ; 
two  into  the  first  phalanx,  the  flexor  brevis  pollicis^ 
and  the  extensor  prlmi  internodli;  the  abductor  and 
adductor  pollicis  are  also  inserted  into  the  first  pha- 
lanx, through  the  medium  of  the  sesamoid  bones; 
the  extensor  secundi'  internodil  and  flexor  longus 
pollicis  are  inserted  into  the  second  phalanx.  Thes.e 
muscles  necessarily  offer  great  resistance  to  the  re- 
duction of  dislocations,  and  therefore  those  of  the 
thumb  are  amongst  the  most  difficult  to  reduce,  if 
any  considerable  time  be  allowed  to  elapse  before 
the  attempt  be  made^ 


486        DISLOCATIONS  OF  THE  FINGERS  AND  TOES. 


DISLOCATION  OF  THE  METACARPAL  BONE  FROM  THE 
OS.  TRAPEZIUM. 

Symptoms,  —  In  the  cases  which  I  have  seen  of 
this  accident,  the  metacarpal  bone  has  been  thrown 
inwards,  between  the  trapezium,  and  the  root  of 
the  metacarpal  bone  supporting  the  fore  finger;  it 
forms  a  protuberance  towards  the  palm  of  the  hand; 
the  thumb  is  bent  backwards,  and  cannot  be  brought 
towards  the  little  finger.  Considerable  pain,  with 
swelling,  is  produced  with  this  accident. 

Mode  adopted  for  reduction.  —  For  the  facility  of 
reduction,  as  the  flexor  muscles  are  much  stronger 
than  the  extensors,  it  is  best  to  incline  the  thumb 
towards  the  palm  of  the  hand  during  extension,  and 
thus  the  flexors  become  relaxed,  and  their  resistance 
diminished.  The  extension  must  be  steadily,  and 
for  a  considerable  time,  supported,  as  no  sudden  vio- 
lence will  effect  the  reduction.  If  the  bone  cannot 
be  reduced  by  simple  extension,  it  is  best  to  leave 
the  case  to  the  degree  of  recovery  which  nature 
will  in  time  produce,  rather  than  divide  the  muscles, 
or  run  any  risk  of  injuring  the  nerves  and  blood- 
vessels. 

Compound  luxation,  —  This  bone  is  sometimes  dis- 
located by  the  bursting  of  a  gun,  which  produces 
compound  luxation  ;  it  can,  in  these  cases,  usually  be 
with  ease  returned  to  its  natural  situation  :  the  in- 
teguments being  brought  and  confined  over  it  by 
suture,  a  poultice  is  applied ;  and  under  common 
circumstances,  where  the  degree  of  bruise  has  not 
been  very  considerable,  a  cure  is  perfected.  Some- 
times, however,  the  metacarpal  bone  becomes  so 
much  detached  from  the  trapezium,  and  the  muscles 
are  so  severely  torn,  that  it  is  necessary  to  remove 
the  thumb,  in  which  case  it  is  best  to  saw  off  the 


DISLOCATIONS  OF  THE  FINGERS  AND  TOES.  487 


articular  surface  of  the  trapezium.  Such  a  case 
happened  lately  to  a  servant  of  Mr  G rover,  of 
Hemel  Hempstead ;  the  metacarpal  bone  of  the 
thumb  was  dislocated,  and  the  muscles  were  so 
much  lacerated  that  it  became  necessary  to  remove 
the  thumb  at  the  os  trapezium  ;  but  the  articular 
surface  of  the  trapezium  projected  so  far  that  the 
integuments  could  not  be  brought  over  it,  1  there- 
fore directed  this  surface  to  be  sawn  off,  through 
the  OS  trapezium ;  and  a  poultice  being  applied,  the 
man  recovered  by  the  granulating  process. 

The  following  case  was  kindly  sent  me  by  Mr  G. 
Cooper. 

Brentford,  April  6^/^,  1820. 

Dear  Sir:~I  some  time  since  promised  to  send 
you  an  account  of  a  compound  dislocation  of  the 
thumb,  which  came  under  my  care  during  the  last 
year;  but  really  I  have  been  in  such  a  whirl  of 
engagements,  that  I  have  not  until  this  evening  had 
leisure  to  look  at  my  notes  of  the  case. 

Case,  —  Master  Arthur  Trimmer,  aged  thirteen 
years,  on  the  2nd  of  February,  1819,  whilst  a  wild 
fire  was  gradually  consuming,  was  in  the  act  of 
adding,  from  a  copper  flask,  dry  powder,  of  which  it 
contained  about  half  a  pound,  when  explosion  took 
place,  and  the  flask  bursting  in  his  hand,  caused  se- 
vere laceration  of  the  palm,  and  a  compound  dislo- 
cation of  the  thumb.  The  Avhole  mass  of  muscle, 
connecting  the  thumb  with  the  hand  was  completely 
torn  through  ;  and  observing  the  thumb  lying  upon 
the  carpus,  dislocated  from  its  articulation  with  the 
trapezium,  I  was  about  to  have  removed  it  by  a 
scalpel,  when  I  saw  the  tendon  of  the  flexor  longus 
pollicis  glisten  in  its  sheath,  uninjured,  as  well  as  the 
tendon  of  the  extensor  longus ;  I  therefore  put  the 


48B       DISLOCATIONS  OF  THE  FINGERS  AND  T0E9. 


parts  in  something  like  a  natural  position,  and  took 
ten  minutes  to  reflect  upon  the  best  mode  of  pro- 
ceeding. The  haemorrhage  was  great  at  the  mo- 
ment, but  the  wound  being  contused  and  lacerated, 
it  ceased  on  slight  pressure. 

Considering  the  thumb  of  the  right  hand  to  be  a 
very  important  part,  1  resolved,  if  possible,  that  it 
should  be  preserved,  assuring  the  friends  of  the 
young  gentleman,  who  were  under  great  apprehen- 
sion lest  tetanus  should  ensue,  that  the  probability 
of  trismus  supervening,  would  not  be  increased  by 
the  attempt  to  save  the  thumb. 

That  intelligent  surgeon,  Mr  Brodie,  having  been 
also  sent  for  at  the  time  of  the  accident,  arrived  in 
about  three  hours,  when  being  of  opinion  with  my- 
self that  there  was  a  chance  that  the  limb  might 
be  saved,  I  brought  the  parts  together  with  three 
ligatures,  two  towards  the  palm,  and  one  on  the 
posterior  part  of  the  hand,  put  on  adhesive  straps, 
allowing  sufficient  room  for  extension,  and  to  the 
hand  and  fore  arm  applied  an  evaporating  lotion. 
Gave  him  at  bed-time  a  pill,  containing  three  grains 
of  calomel  and  one  of  opium,  and  in  the  morning  a 
cathartic  mixture. 

February  3rd.  Had  a  restless  night,  but  the  part 
not  very  painful. 

February  4th.  His  pulse  running  120,  and  hard, 
I  took  away  about  eight  ounces  of  blood,  and  order- 
ed him  the  effervescing  mixture,  paying  attention  to 
the  state  of  his  bowels.  Continued  the  antiphlogis- 
tic plan. 

February  7th.  Removed  the  dressings  and  liga- 
tures, and  had  the  pleasure  to  find  that  considerable 
adhesion  had  taken  place  ;  that  no  tetantic  symptoms 
made  their  appearance,  and  that  every  day  he  suf- 
fered less  from  constitutional  irritation. 

February  9th.     Again  removed  the  dressings. 


DISLOCATIONS  OF  THE  FINGERS  AND  TOES.  489 


wound  looking  healthy,  and  suppuration  not  consid- 
erable ;  I  therefore  continued  to  dress  with  adhesive 
plaster,  small  quantities  of  lint,  and  over  that  a 
bandage  about  an  inch  wide  and  two  yards  long,  by 
means  of  which  sufficiently  equable  pressure  could 
be  made  to  promote  the  inosculation  of  granulating 
surfaces,  as  well  as  to  produce  a  tolerable  even  ex- 
ternal state  of  the  parts  during  the  advance  of  the 
adhesive  process. 

From  this  time  it  was  dressed  every  second  day, 
and  on  the  sixteenth  I  began  to  give  it  passive  motion, 
at  first,  by  simply  bending  the  first  phalanx  of  the 
thumb^  so  as  to  break  down  any  adhesions  that  might 
have  taken  place  between  the  tendons  and  their 
thecae.  By  the  twenty-third  1  gave  trifling  motion 
to  the  second  phalanx,  and  towards  the  end  of  the 
month  the  wound  was  healed.  Through  the  month 
of  March  I  gradually  increased  the  motion,  and  on 
the  first  of  April  my  little  patient  left  Brentford  on 
a  visit  to  the  Isle  of  Wight,  with  injunctions  to  give 
daily  motion  to  the  joint;  and  I  am  happy  to  add,  he 
now  makes  use  of  it  in  writing  as  well  as  ever,  and 
€rids  the  thumb  perfectly  useful  for  all  the  ordinary 
purposes  of  life. 

I  am,  dear  Sir, 

Most  truly  yours, 

George  Cooper. 


DISLOCATION  OP  THE  FIRST  PHALANX. 

Diagnostic  marks  of  simple  dislocation  of  the  first 
phalanx.  —  This  accident  may  be  either  simple  or 
compound.  I  shall  first  describe  the  simple  disloca- 
tion. In  this  accident  the  first  phalanx  is  thrown 
back  upon  the  metacarpal  bone ;  the  lower  extremi- 
62 


490       DISLOCATIONS  OF  THE  FINGERS  AND  TOES. 


ty  of  the  latter  projects  very  much  inward  towards 
the  palm  of  the  hand,  and  the  extremity  of  the 
phalanx  projects  backwards.  The  motion  of  that 
joint  is  lost,  but  that  of  the  thumb,  through  the 
medium  of  the  metacarpal  bone  and  trapezium, 
remains  free  ;  so  that,  as  an  opponent  to  the  fingers, 
its  power  of  action  continues;  but  with  respect  to 
flexion  and  extension,  which  are  performed  between 
the  metacarpal  bone  and  the  first  phalanx,  they  are 
destroyed  by  the  dislocation. 

Mode  of  reduction.  —  The  extension  is  to  be  made 
by  bending  the  thumb  towards  the  palm  of  the  hand, 
to  relax  the  flexor  muscles  as  much  as  possible;  and 
the  following  is  the  mode  of  applying  the  extending 
force,  which  may  be  considered  as  the  general  mode 
to  be  adopted  in  dislocations  of  the  toes,  thumb,  and 
fingers.  The  hand  is  to  be  first  steeped  in  warm 
water  for  a  considerable  time,  to  relax  the  parts  as 
much  as  possible  ;  then  a  piece  of  thin  wetted  leather, 
wash-leather  for  instance,  is  to  be  put  around  the 
first  phalanx,  and  as  closely  adapted  to  the  thumb  as 
possible  ;  a  portion  of  tape,  about  two  yards  in  length, 
is  then  to  be  applied  upon  the  surface  of  the  leather, 
in  the  knot  which  is  called  by  sailors  the  clove  hitch 
(see  Plate),  {or  this  becomes  tighter  as  the  extension 
proceeds.  An  assistant  places  his  middle  and  fore 
finger  between  the  thumb  and  fore  finger  of  the 
patient,  and  makes  the  counter  extension,  whilst  the 
surgeon,  assisted  by  others,  draws  the  first  phalanx 
from  the  metacarpal  bone,  directing  it  a  little  inward 
towards  the  palm  of  the  hand. 

The  extension  should  be  supported  for  a  consider- 
able length  of  time,  and  if  success  does  not  attend 
the  surgeon's  efforts,  it  is  right  to  adopt  the  follow- 
ing plan.  The  leather  and  sailor's  knot  are  to  be 
applied  as  above,  and  a  strong  worsted  tape  is  to  be 
carried  between  the  metacarpal  bone  of  the  thumb 
and  the  fore  finger;  the  arm  is  then  to  be  bent 


DISLOCATIONS  OF  THE  FINGERS  AND  TOES.  491 


around  a  bed-post,  and  the  worsted  tape  fixed  to  it; 
a  pulley  is  then  to  be  hooked  to  the  tape  which  sur- 
rounds the  first  phalanx,  and  extension  is  to  be  made  : 
this  mode  is  ahnost  sure  to  succeed.  If,  however, 
under  the  steadiest,  best  directed,  and  most  perse- 
vering attention,  the  bone  be  not  reduced,  a  disap- 
pointment w^iich  will  sometimes  happen  in  disloca- 
tions which  have  been  neglected,  then  the  surgeon's 
efforts  must  cease  ;  no  operation  for  the  division  of 
parts  should  be  made,  as  the  patient  will  have  a 
very  useful  thumb  after  a  time,  even  without  re- 
duction. 

Treatment  of  compound  dislocation  of  the  thumb, — 
In  compound  dislocations  of  the  first  phalanx  of  the 
thumb,  if  there  be  much  difficulty  in  its  reduction, 
and  the  wound  be  large,  it  is  best  to  saw  off  the  ex- 
tremity of  the  bone,  rather  than  to  bruise  the  parts 
by. long  continued  extension:  they  are  to  be  healed 
by  adhesion;  and  if  passive  motion  be  begun  early, 
a  joint  will  soon  be  formed,  and  a  very  useful  mem- 
ber remain.  In  this  case,  lint,  dipped  in  blood,  is  to 
be  applied  to  the  wound  :  a  roller  must  be  bound 
round,  and  the  part  kept  cool  by  evaporating  lotions 
for  several  days,  until  the  wound  be  healed. 

I  very  recently  saw  the  following  case  of  compound 
dislocation  of  this  bone. 

Case,  —  A  gentleman  came  to  my  house,  whose 
first  phalanx  had  been  thrown  upon  the  back  of  the 
metacarpal  bone  of  the  thumb  by  the  bursting  of  a 
gun.  The  flexor  muscles  and  the  abductor  were 
much  lacerated  just  below  the  os  trapezium  ;  the 
extensors  were  not  injured.  I  applied  the  tape  to 
the  first  phalanx,  and  extending,  easily  reduced  it; 
I  then  brought  the  edges  of  the  integuments  toge- 
ther by  suture,  directing  a  poultice  to  be  applied,  on 
account  of  the  great  contusion  of  the  parts ;  and 
the  recovery  was  very  complete. 


492       DISLOCATIONS  OF  THE  FINGERS  AND  TOES, 


DISLOCATION  OP  THE  SECOND  PHALANX. 

Simple,  —  If  this  be  a  sim|3le  dislocation  the  best 
mode  of  reducing  it  is,  that  the  surgeon  should  grasp 
the  back  of  the  first  phalanx  with  his  fingers,  apply 
his  thumb  upon  the  fore  part  of  the  dislocated  pha- 
lanx, and  then  bend  it  upon  the  first  as  much  as  he 
possibly  can. 

Compound.  —  In  compound  dislocations  of  this 
joint  (of  which  I  have  given  a  plate),  it  is  best  to 
saw  off  the  extremity  of  the  second  phalanx,  taking 
care  not  to  injure  the  tendon  which  is  torn  through; 
for  when  the  bone  is  removed,  the  ends  of  the  ten- 
don may  be  readily  approximated,  and  adapted  to 
each  other.  The  extremity  of  the  tendon  should 
be  smoothed  by  a  knife,  and  the  part  be  then  bound 
up  in  hnt,  dipped  iri  blood,  confined  by  a  roller  ;  and 
it  should  be  kept  quiet  for  a  fortnight  or  three 
"weeks,  when  passive  motion  may  be  begun^ 


DISLOCATION  OF  THE  RIBS. 


Authors  describe  different  species  of  dislocations 
of  the  ribs  :  their  heads  are  said  to  be  thrown  from 
their  articulation  with  the  vertebrge  forwards  upon 
the  spine.  If  this  accident  ever  does  occur,  it  is 
certainly  extremely  rare,  and  must  be  very  difficult 
of  detection. 

Heads  of  ribs,  — A  person,  by  falling  on  his  back 
upon  some  pointed  body,  may,  however,  receive  a 
blow  upon  his  ribs,  by  which  they  may  be  driven 
from  their  articulations. 

Symptoms.  —  Such  an  injury  would  produce  the 
usual  symptoms  of  fracture  of  these  bones  :  their 
motions  v^^ould  be  painful,  and  respiration  necessarily 
difficult. 

Treatment  —  The  treatment  which  would  be  re- 
quired, would  also  be  the  same  as  that  which  is 
pursued  in  fracture  of  the  ribs :  viz,  the  abstraction 
of  blood,  and  the  application  of  a  circular  bandage  : 
the  former  to  prevent  inflammation  of  the  pleura 
and  lungs;  the  latter  to  lessen  the  motion  of  the 
ribs.  Any  attempt  made  to  effect  their  reduction 
would  be  entirely  fruitless. 


494 


DISLOCATION    OF  THE  RIBS. 


Cartilages,  —  The  cartilages  connecting  the  ribs 
with  the  sternum,  frequently  appear  to  have  been 
dislocated  from  the  extremities  of  the  ribs,  and 
sometimes  from  the  sternum.  Mothers  have  sever- 
al times  brought  their  children  to  me,  saying,  '  My 
child  has  sometime  since  had  a  fall,  and  see  how  the 
form  of  its  breast  is  altered.'  The  sixth,  seventh, 
and  eighth  cartilages  of  the  ribs  are  most  frequent- 
ly the  subjects  of  this  alteration  of  form:  and  when 
the  ribs  are  carefully  examined,  it  is  found  that  their 
natural  arch  is  diminished,  their  sides  flattened,  and, 
consequently,  the  extremities  of  the  ribs,  with  their 
cartilages,  thrust  forward.  The  appearance  which 
is  thus  produced  is  the  result  of  constitutional  weak- 
ness, and  not  of  the  accident  to  which  it  is  attributed. 

Termination  of  cartilage ;  forcibly  separated^  frc. 
—  The  termination  of  the  cartilages  at  the  sternum 
sometimes  projects  from  a  similar  cause,  giving  rise 
to  the  same  false  impression  upon  the  minds  of  the 
parents,  that  the  circumstance  must  have  arisen  from 
accident,  and  not  from  disease.  Sometimes,  how- 
ever, but  very  rarely,  a  cartilage  is  torn  from  the 
extremity  of  the  rib,  and  projects  over  its  surface  ; 
when  this  happens,  a  similar  treatment  is  required 
as  in  fracture  of  the  ribs.  The  patient  is  to  be 
directed  to  make  a  deep  inspiration,  and  then  the 
projecting  cartilage  is  to  be  pressed  into  its  natural 
situation  ;  a  long  piece  of  wetted  pasteboard  should 
be  placed  in  the  course  of  three  of  the  ribs  and 
their  cartilages,  the  injured  rib  being  in  the  centre  : 
this  dries  upon  the  chest,  takes  the  exact  form  of 
the  parts,  prevents  motion,  and  affords  the  same 
support  as  a  sphnt  upon  a  fractured  limb.  A  flannel 
roller  is  to  be  applied  over  this  splint,'  and  a  system 
of  depletion  pursued,  to  prevent  inflammation  of  the 
thoracic  viscera. 


INJURIES  OF  THE  SPINE. 


Dislocations  very  rare  It  has  been  generally 

stated  by  surgeons  that  dislocations  of  the  spinal 
column  frequently  occur;  but  if  luxation  of  the  spine 
ever  does  happen,  it  is  extremely  rare;  as  in  the 
numerous  instances  which  I  have  seen  of  violence 
done  to  the  spine,  I  have  never  witnessed  a  separa- 
tion of  one  vertebra  from  another  through  the  in- 
tervertebral substance,  without  fracture  of  the  ar- 
ticular processes;  or,  if  those  processes  remain  un- 
broken, without  a  fracture  through  the  bodies  of  the 
vertebrae.  Still  I  would  not  be  understood  to  deny 
the  possibility  of  dislocation  of  the  cervical  verte- 
brae, as  their  arliculatory  processes  are  placed  more 
obliquely  than  those  of  the  other  vertebrae.  I  must, 
however,  observe,  that  from  the  vicinity  of  our  hos- 
pitals to  the  river,  sailors  are  often  brought  into 
them  with  injuries  of  the  spine,  by  falls  from  the 
yard-arm  to  the  deck  ;  and  as  there  is  almost  always 
an  opportunity  of  inspection  in  these  cases,  a  dislo- 
cation must  be  very  unusual,,  since  I  have  never  met 
with  a  single  instance  of  it,  those  injuries  having  all 
proved  to  be  fractures  with  displacement. 


496 


INJURIES  OF  THE  SPINE. 


I  am  well  aware  that  respectable  surgeons  have 
described  dislocations  as-  occurring  in  tlie  cervical 
vertebrae,  but  I  wish  to  state  my  own  experience, 
with  no  further  reference  to  that  of  others. 

The  following  short  account  of  the  structure  of 
the  spine,  is  given  merely  to  revive  the  ideas  which 
may  have  faded  from  the  memory. 

Structure;  bones.  —  The  spinal  column  is  composed 
of  twenty-four  vertebrae,  which  are  divided  into 
three  classes;  namely,  the  cervical,  dorsal,  and  the 
lumbar;  they  are  very  strongly  connected  by  four 
articular  processes,  and  are  firmly  joined  by  an  elas- 
tic substance,  which  proceeds  from  the  broad  surface 
of  the  body  of  one  vertebra  to  that  of  the  other. 
The  spinous  processes  of  many  of  the  vertebrae, 
and  particularly  those  nearest  to  the  centre  of  the 
column  are  locked  together,  one  being  admitted  into 
a  depression  of  the  other. 

Invertebral  substance  ;  ligaments,  S^c,  —  The  bodies 
of  the  vertebrae  are  united  by  a  ligamento  cartilagi- 
nous substance,  extremely  elastic,  and  composed  of 
concentric  lamellae,  connected  by  oblique  fibres, 
which  decussate  each  other,  but  in  the  centre  be- 
come mucous,  so  as  to  form  a  pivot,  which  supports 
the  central  line  of  the  vertebrae  ;  whilst  the  elasti- 
city and  compressibility  of  the  outer  edge  of  this 
uniting  medium,  allows  the  vertebrae  to  move  upon 
this  centre  in  all  directions.  The  column  is  also 
farther  connected  by  an  anterior  spinal  ligamejit, 
which  proceeds  from  the  second  vertebrae  of  the 
neck  to  the  sacrum,  and  is  united  to  all  the  bodies 
of  the  vertebrae,  excepting  the  first.  There  is  also 
a  posterior  spinal  ligament,  situated  within  the  canal 
of  the  spinal  column,  and  proceeding  from  the  se- 
cond vertebra  ;  but  it  is  also  intermixed  with  the 
perpendicular  ligament ;  and  descending  to  the  sa- 
crum, it  sends  out  lateral  processes  to  the  superior 


INJURIES  OF  THE  SPINE. 


491 


and  inferior  edges  of  the  bodies  of  the  vertebrae. 
Intervertebral  ligaments  also  pass  in  a  crucial  direc- 
tion from  vertebra  to  vertebra.  The  articular  pro- 
cesses are  united  by  capsular  ligaments,  and  the 
transverse  processes  have  ligaments  passing  from 
the  one  to  the  other.  Between  the  arches  of  the 
roots  of  the  spinous  processes  is  placed  an  elastic 
ligament,  called  the  ligamentum  subjlamm^  which  al- 
lows of  considerable  separation  of  the  spinous  pro- 
cesses; and,  by  its  elasticity,  approximates  them, 
rendering  muscular  support  for  the  erect  position  of 
the  body  less  necessary.  The  vertebrse  of  the  neck 
are  united  at  their  spinous  processes  by  an  elastic 
ligamentous  substance,  which  is  termed  the  ligamen- 
tum nuchcB. 

Capsular.  — The  head  is  connected  to  the  spinal 
column  by  capsular  ligaments,  enclosing  the  condyles 
of  the  OS  occipitis  and  the  articular  processes  of  the 
atlas,  or  the  first  vertebra. 

Circular. — circular  ligament  proceeds  from  the 
foramen  magnum  to  the  edge  of  the  aperture  of 
the  first  vertebra. 

Perpendicular,  —  ^  perpendicular  ligament  passes 
from  the  anterior  part  of  the  foramen  magnum 
to  the  dentiform  process  of  the  second  vertebra. 

Lateral.  —  Lateral  ligaments  proceed  from  the 
edge  of  the  foramen  magnum  and  first  vertebra  on 
each  side,  and  are  united  to  the  dentiform  process 
of  the  second  vertebra  :  these  ligaments  limit  the 
lateral  motions  of  the  head. 

Transverse.  —  The  first  vertebra  of  the  neck  is 
united  to  the  second  by  means  of  a  transverse  liga- 
ment, which  is  also  fixed  to  the  first  vertebra  on 
each  side,  and  passes  behind  the  dentifofm  process 
of  the  second  vertebra. 

The  spinal  column,  from  the  two  important  pur- 
poses which  it  serves,  namely,  that  of  supporting 

63 


498 


INJURIES  OP  THE  SPINE. 


the  head  and  all  that  part  of  the  body  situated 
above  the  pelvis,  and  also  from  its  containing  and 
protecting  the  spinal  marrow,  upon  which  the  voli- 
tion and  sensation  of  the  extremities  depend,  is,  by 
the  number  of  its  bones,  the  strength  of  its  joints, 
and  its  connexion  with  the  bones  of  the  chest,  most 
carefully  protected  from  external  injury. 

Effects  of  injuries,  —  The  etfects  which  are  pro- 
duced by  violence  done  to  the  spinal  cord  are  very 
similar  to  those  which  are  produced  by  injuries  to 
the  brain;  for  example:  — 

Concussion, 

Extravasation, 

Fracture, 

Fracture  with  depression, 
Suppuration  and  ulceration. 


CONCUSSION  OF  THE  SPINAL  MARROW- 

Concussion,  —  When  a  person  receives  a  very  se- 
vere blow  upon  the  spine,  or,  from  any  great  force, 
has  it  very  suddenly  bent,  a  paralysis  of  the  parts 
beneath  will  frequently  succeed,  in  a  degree  propor- 
tionable to  the  violence  of  the  injury  ;  but  after  such 
an  effect,  the  person,  in  general,  gradually  recovers 
the  motion  and  sensation  of  the  parts. 

Case,  —  A  man  was  admitted  into  Guy's  Hospital 
under  the  care  of  Dr  Curry,  who  had  received  a 
severe  blow  from  a  piece  of  wood,  which,  falling 
upon  his  loins,  knocked  him  down  ;  and  as  he  came 
to  the  hospital  on  the  regular  day  of  admission,  and 
not  immediately  after  he  had  received  the  injury, 
he  was  placed  amongst  the  physicians'  patients. 
His  lower  extremities  were  in  a  great  degree  de- 
prived of  motion,  and  their  sensibility  was  much 


INJURIES  OF  THE  SPINE. 


499 


diminished.  Wh'en  resting  upon  his  back  in  bed  he 
could  slightly  draw  up  his  legs,  but  could  not  bend 
them  to  a  right  angle  with  the  thigh  ;  and  a  con- 
siderable time  elapsed  before  he  could  make  the 
muscles  of  the  lower  extremities  obey  the  effort  of 
his  will.  As  there  was  still  the  appearance  of  se- 
vere contusion  and  much  deep  seated  tenderness  in 
the  situation  of  the  blow  upon  the  loins,  Dr  Curry 
ordered  blood  to  be  repeatedly  drawn  away  by  cup- 
ping, and  the  bowels  to  be  acted  upon  by  calomel; 
and  when  the  pain  and  tenderness,  in  consequence 
of  the  contusion,  had  been  removed,  a  blister  was 
applied  to  the  loins,  and  a  discharge  supported  for 
three  weeks  by  the  application  of  the  unguentum 
sabinae.  The  liniment  ammonias  was  ordered  to  be 
daily  rubbed  upon  the  lower  extremities.  In  six 
weeks  the  motion  and  sensation  of  his  legs  had  almost 
entirely  returned,  and  he  was  then  directed  to  be 
submitted  to  the  influence  of  electricity.  By  this 
treatment,  in  ten  weeks  he  completely  recovered. 

I  lately  attended  a  gentleman,  who,  by  a  fall  from 
his  gig,  had  received  a  severe  blow  upon  his  loins, 
and  who  had,  at  first,  great  difficulty  in  discharging 
both  his  urine  and  fasces  ;  but  he  was  relieved  by 
fomentation  and  cupping. 


EXTRAVASATION   IN  THE  SPINAL  CANAL. 

Extravasation  ;  spinal  morrow  examined  in  dissec^ 
tion.  —  A  very  severe  blow  upon  the  vertebrae  will 
sometimes  produce  extravasation  upon  the  spinal 
chord,  but  more  frequently  upon  the  sheath  upon 
which  it  is  contained.  Of  late  years  it  has  been  our 
custom,  in  examining  dead  bodies,  to  saw  off  the 
spinous  processes  of  the  vertebrae,  the  more  accu- 


500 


INJURIES  OF  THE  SPINE. 


rately  to  examine  the  spinal  marrow  ;  and  under 
such  circumstances,  in  cases  of  severe  injury,  blood 
has  been  several  times  found  on  the  outer  side  of 
the  spinal  sheath  ;  and,  in  one  instance,  it  occurred 
upon  the  spinal  marrow,  just  above  thecauda  equina. 

The  case  which  best  illustrates  this  subject  is  one 
which  I  visited  with  Dr  Baillie,  and  Mr  Heaviside, 
and  the  particulars  of  which  I  have  obtained  from 
Mr  Heaviside,  whom  1  have  ever  found  ready  to 
make  his  beautiful  anatomical  collection  useful  to 
the  profession. 

Case. —  Master  — ,  a  fine  youth,  aged  twelve 

years,  in  June,  1814,  was  swinging  in  a  heavy  wooden 
swing,  and  in  just  commencing  the  motion  forward, 
was  caught  by  a  line  which  had  got  under  his  chin, 
by  which  accident  his  bead  and  the  whole  of  the 
cervical  vertebra}  were  violently  strained  ;  as,  how- 
ever, the  line  slipt  immediately  off,  he  thought  no 
more  of  it.  Subsequently  to  the  accident,  for  some 
months,  he  was  not  aware  of  any  pain  or  inconve- 
nience, but  his  school-fellows  observed  that  he  was 
less  active  than  usual :  instead  of  filling  up  his  time 
by  play,  he  would  be  lying  on  the  school  forms,  or 
leaning  on  a  stile  or  gate  when  in  the  fields.  They 
were  always  teasing  him  on  this  account;  and  at 
last  he  was  persuaded  that  he  was  weaker  than  he 
used  to  be.  From  this  time  he  continued  to  decline 
both  in  strengtli  and  power.  About  the  middle  of 
May  following  he  came  to  London.  His  complaints 
were  occasional  pains  in  the  head,  which  were  more 
severe  and  frequent  about  the  back  of  his  neck 
(where  a  blister  had  been  applied  without  relief) 
and  down  his  back.  The  muscles  at  the  back  of 
the  head  and  neck  were  stiff,  indurated,  and  very 
tender  to  external  pressure.  He  felt  pain  in  moving 
his  head  or  neck  in  any  direction  :  added  to  these 


INJURIES  OF  THE  SPINE. 


501 


symptoms,  there  was  a  great  deficiency  in  the  volun- 
tary powers  of  motion,  especially  in  the  limbs. 

May  18th.  Two  setons  were  made  in  the  neck, 
and  he  was  ordered  various  medicines,  none  of  which 
proved  useful. 

May  29th.  His  complaints  and  the  paralytic 
affection  of  his  limbs  were  getting  much  worse,  added 
to  which  he  felt  a  most  vehement  hot  burning  pain 
in  the  small  of  his  back.  This,  by  the  next  day, 
was  succeeded  by  a  sense  of  extrenje  coldness  in  the 
same  part.  Some  time  after,  the  same  pain  occur- 
red higher  up  in  the  back,  and  then  disappeared. 
Pulse  and  heat  natural. 

June  3d.  A  consultation  of  Dr  Baillie,  Dr  Pem- 
berton,  Mr  A.  Cooper  and  Mr  Heaviside  was  held, 
and  the  application  of  mercury  was  determined  on. 
The  pil.  hydr.  was  taken  for  a  few  days;  but,  as  it 
ran  off  by  the  bowels,  mercurial  frictions  were  con- 
sequently preferred.  He  felt  his  limbs  getting  every 
day  weaker,  but  his  neck  was  more  free  from  pain 
when  moved,  and  he  was  more  capable  of  moving 
it  by  his  own  natural  efforts. 

June  7th.  His  respiration  became  laborious  ;  he 
passed  a  bad  night ;  on  the  following  day  all  his 
symptoms  increased,  and  at  five  in  the  afternoon  he 
expired. 

Examination. 
Dissection.  —  The  whole  contents  of  the  head  were 
carefully  examined  and  found  perfectly  healthy;  but 
upon  sawing  out  the  posterior  parts  of  the  cervical 
vertebree,  the  theca  vertebralis  was  found  over- 
flowed with  blood,  which  was  effused  between  the 
theca  and  the  enclosing  canals  of  bone.  The  dis- 
section being  farther  prosecuted,  this  effusion  ex- 
tended from  the  first  vertebra  of  the  neck  to  the 
second  vertebra  of  the  back,  both  included. 


502 


INJURIES  OP  THE  SPINE. 


The  preparation  only  shows  a  small  proportion  of 
the  effused  blood  which  had  become  coagulated  on 
the  theca,  because  much  of  it,  being  fluid,  escaped 
in  the  act  of  removal. 


FRACTURE    OF  THE  SPINE. 

Produce  symptoms  of  irritation  on  pressure, — These 
accidents,  even  when  the  bones  retain  their  situation, 
produce,  by  admitting  unnatural  variations  in  the 
positions  of  the  spinal  column,  very  extraordinary 
symptoms,  and  sometimes  sudden  death.  Mr  Else, 
who  preceded  Mr  Cline  as  teacher  of  anatomy  at 
St  Thomas's  Hospital,  used  to  mention  the  following 
case  in  his  lectures. 

Case.  —  A  woman,  who  was  in  the  venereal  ward 
at  St  Thomas's  Hospital,  and  who  was  then  under  a 
mercurial  course,  while  sitting  in  bed,  eating  her 
dinner,  was  observed  to  fall  suddenly  forward;  and 
the  patients  hastening  to  her,  found  that  she  was 
dead.  Upon  examination  of  her  body,  the  dentiform 
process  of  the  second  vertebra  had  been  broken  off : 
the  head,  in  falling  forwards,  had  forced  the  root  of 
the  process  back  upon  the  spinal  marrow,  which  occa- 
sioned her  instant  dissolution. 

At  the  time  I  lived  with  Mr  Cline,  as  his  appren- 
tice, the  following  case  occurred  in  his  practice. 

Case  ;  fracture  of  the  atlas.  —  A  boy,  about  three 
years  of  age,  from  a  severe  fall,  injured  his  neck  ; 
and  the  following  symptoms  succeeding  the  accident, 
Mr  Cline  was  consulted. 

Symptoms. —  He  was  obliged  to  walk  carefully  up- 
right, as  persons  do  when  carrying  a  weight  on  the 
head  ;  and  when  he  wished  to  examine  any  object 
beneath  him,  he  supported  his  chin  upon  his  hands 


INJURIES  OF  THE  SPINE. 


503 


and  gradually  lowered  his  head,  (o  enable  him  to 
direct  his  eyes  downwards ;  but  if  the  object  was 
above  him,  he  placed  both  his  hands  upon  the  back 
of  his  head,  and  very  gradually  raised  it  until  his 
eyes  caught  the  point  he  wished  to  see. 

If,  in  playing  with  other  children,  they  ran  against 
him,  it  produced  a  shock  which  caused  great  pain, 
and  he  was  obliged  to  support  his  chin  with  his 
hand,  and  to  go  immediately  to  a  table,  upon  which 
he  placed  his  elbows,  and  thus  supporting  his  head 
he  remained  a  considerable  time,  until  the  effects  of 
concussion  had  ceased.  He  died  about  twelve  months 
after  the  accident;  and  upon  the  inspection  of  his 
body,  which  was  conducted  by  Mr  Cline,  the  first 
vertebra  of  the  neck  was  found  broken  across,  so 
that  the  dentiform  process  of  the  second  vertebra 
had  so  far  lost  its  support,  that  under  different  incli- 
nations of  the  head,  it  required  great  care  to  prevent 
the  spinal  marrow  from  being  compressed  by  it;  and 
as  the  patient  could  not  depend  upon  the  action  of 
the  muscles  of  the  neck,  he  therefore  used  his  hands 
to  support  the  head  during  different  motions  and 
positions. 

Spinous  process,  —  Portions  of  the  spinous  process- 
es are  sometimes  broken  off,  but  these  accidents  do 
not  usually  affect  the  spinal  marrow,  unless  when 
attended  with  considerable  concussion.  Mr  Ashton 
Key,  in  dissecting  a  subject  at  St  Thomas's  Hospi- 
tal, found  a  spinous  process  loose,  which  he  kindly 
brought  to  me,  with  the  following  account :  '  The 
fractured  vertebra  was  the  third  dorsal ;  the  cause 
of  the  accident  I  could  not  ascertain,  as  it  occurred 
iri  a  subject  brought  into  the  dissecting-room.  There 
was  a  complete  articulation  formed  between  the 
broken  surfaces,  which  had  become  covered  with  a 
thin  layer  of  cartilage.  The  synovial  membrane 
and  capsular  ligaments  resembled  those  of  other 


504 


INJURIES  OF  THE  SPINE. 


joints,  excepting  that  the  former  was  more  vascular. 
The  fluid  within  the  joint  had  the  hibricating  feel 
characterizing  synovia.' 

Case.  —  A  boy  was  admitted  into  Guy's  Hospital, 
who  had  been  endeavouring  to  support  a  heavy 
wheel,  by  putting  his  head  between  the  spokes,  and 
receiving  its  weight  upon  his  shoulders.  The  wheel 
overbalanced  him,  and  he  fell,  bent  double.  When 
he  was  brought  into  Guy's  Hospital,  although  he 
had  been  perfectly  straight  before,  he  had  the  ap- 
pearance of  one  who  had  long  suffered  from  distort- 
ed spine,  yet  this  injury  had  not  produced  paralysis 
of  the  lower  extremities.  Three  or  four  of  the 
spinous  processes  had  been  broken  off,  and  the  mus- 
cles torn  on  one  side,  so  as  to  give  an  obliquity  to 
the  situations  of  the  fractured  portions.  The  boy 
quickly  recovered  without  any  particular  attention, 
and  was  discharged  with  the  free  use  of  his  body 
and  limbs,  but  he  still  remained  deformed. 


FRACTURES  OF  THE  BODIES  OF  THE  VERTEBRAE,  WITH 
DISPLACEMENT. 

Displacement  of  the  vertehrce. — These  fractures 
frequently  come  under  our  observation,  producing 
displacement  of  the  vertebrae.  As  the  syojptoms 
and  result  of  the  accident  differ  according-  to  the 
situation  of  the  fractured  bones,  these  injuries  may 
be  divided  into  two  classes;  firsts  those  which  occur 
above  the  third  cervicle  vertebra;  and,  secondly^ 
those  which  occur  below  that  bone. 

These  accidents  fatal,  —  In  the  first  class,  the  ac- 
cident is  almost  always  immediately  fatal,  if  the  dis- 
placement be  to  the  usual  extent.    Death,  in  the 


INJURIES  OF  THE  SPINE. 


505 


second  class,  occurs  at  various  periods  after  the  inju- 
ry. The  origin  of  the  phrenic  nerve,  from  the  third 
and  fourth  cervical  pair,  is  the  reason  of  this  differ- 
ence ;  for  as  the  parts  below  are  paralyzed  by  the 
pressure  upon  the  spinal  chord,  if  the  accident  be 
below  the  fourth  cervical  vertebra,  the  phrenic 
nerve  retains  its  functions,  and  the  diaphragm  sup- 
ports respiration;  but  if,  on  the  contrary,  the  frac- 
ture be  situated  above  the  origin  of  this  nerve,  death 
immediately  ensues.  It  is  true,  that  a  small  filament 
of  the  second  cervical  nerve  contributes  to  the  Ibr- 
mation  of  the  phrenic,  but  is  in  itself  insufficient  to 
support  respiration  under  fracture  of  the  third 
vertebra. 

Displacement  below  the  phrenic  nerve,  8^c, — The 
effects  which  arise  from  fracture  and  displacement 
of  the  spine,  below  the  origin  of  the  phrenic  nerve, 
depend  upon  the  proximity  of  the  accident  to  the 
head.  If  the  lumbar  vertebrae  be  displaced,  the 
lower  extremities  are  rendered  so  completely  insen- 
sible, that  no  injury  inflicted  upon  them  can  be  per- 
ceived by  the  patient.  Pinching,  burning  with  caus- 
tic, or  the  application  of  a  blister,  are  alike  unfell. 
The  power  of  volition  is  completely  destroyed,  not 
the  smallest  influence  over  the  muscles  remaining. 
The  sphincter  ani  loses  its  power  of  resistance  to  the 
peristaltic  motion  of  the  intestines,  and  the  faeces 
pass  off  involuntarily.  The  bladder  is  no  longer  able 
to  contract,  and  the  urine  is  retained  until  drawn  off 
by  a  catheter,  and  yet  the  involuntary  powers  of  the 
limbs  remain  nearly  the  same  as  before.  The  circu- 
lation proceeds,  although  perhaps  somewhat  more 
languidly,  but  sufficiently  to  preserve  their  heat;  and 
local  inflammation  can  be  excited  in  them.  A  blister 
applied  upon  the  inner  side  of  the  thigh  or  leg,  of 
which  the  patient  is  wholly  unconscious,  will  still  in- 
flame, vesicate,  and  heal ;  showing  that  the  involun- 
tary functions  may  proceed  in  parts  which  are  cut 

64 


506 


INJURIES  OF  THE  SPINE. 


off  from  their  connexion  with  the  brain  and  spinal 
marrow.*  The  penis,  under  these  circumstances,  is 
generally  erect.  Patients  die  from  this  injury  at 
various  periods,  according  to  the  degree  of  displace- 
ment of  the  vertebrae.  In  general,  in  fractures  of 
the  lumbar  vertebrae,  the  patient  dies  within  the 
space  of  a  month  or  six  weeks  after  the  injury;  and 
usually  for  some  time  before  death,  the  urine  passes 
off  involuntarily,  from  extreme  debility.  I  remem- 
ber a  patient  of  Mr  Birch,  in  St  Thomas's  Hospital, 
who  lived  more  than  two  years  after  this  accident, 
and  then  died  of  gangrene  of  the  nates. 

Displacement  of  the  dorsal  vertebrce,  —  in  fractures 
and  displacement  of  the  dorsal  vertebrae,  the  symp- 
toms are  very  similar  to  those  described  in  fractures 
of  the  lumbar ;  but  the  paralysis  extends  higher, 
and  the  abdomen  becomes  excessively  inflated.  I 
remember  one  of  our  pupils  saying,  when  a  patient 
was  brought  into  Guy's  Hospital  who  had  suffered 
from  injury  to  the  dorsal  vertebrae,  *  Surely  this  man 
has  ruptured  his  intestines,  for  observe  how  his  ab- 
domen is  distended.'  But  the  first  faecal  evacuation 
relieved  this  state,  and  proved  that  it  had  merely 
arisen  from  excessive  flatulency.  This  symptom 
proceeds  from  diminished  nervous  influence  in  the 
intestines  ;t  for  although  their  peristaltic  motion  can 
proceed  independently  of  the  brain  and  spinal  mar- 
row, yet  it  is  quite  certain  that  the  involuntary  func- 
tions of  the  intestines,  like  those  of  the  heart,  can 
be  influenced  by  the  brain  and  spinal  marrow  ;  for 
we  see  even  states  of  the  mind  producing  affections 

*  1  have  always  thought  that  although  sensation  and  volition 
depend  upon  the  brain,  the  spinal  marrow,  and  the  nerves,  yet 
the  involuntary  functions  depend  principally  upon  the  nerves. — 
A.  C. 

t  Preceding  dissolution,  in  almost  all  diseases,  a  great  evolu- 
tion of  air  into  the  intestines  is  observed,  and  from  the  same 
cause.  —  A.  C, 


INJURIES  OF  THE  SPINE. 


507 


of  the  intestines ;  one  state  rendering  them  torpid, 
and  another  irritable  ;  as  we  see  the  heart  leaping 
with  joy,  and  depressed  by  disappointment.  We 
also  observe  pressure  on  the  brain  rendering  the 
intestines  very  difficult  of  excitement,  even  through 
the  influence  of  the  strongest  aperients.  From  dis- 
placement of  the  dorsal  vertebrae,  death  sooner  suc- 
ceeds than  in  similar  injuries  to  the  lumbar,  the 
patient  usually  surviving  the  accident  not  more  than 
a  fortnight  or  three  weeks  ;  but  still  I  knew  a  case 
of  a  gentleman  in  the  city,  who  met  with  this  acci- 
dent, and  who  lived  rather  more  than  nine  months. 
The  period  of  existence  is  short  or  protracted,  as 
the  injury  is  near  or  distant  from  the  cervical  verte- 
brae, and  as  the  displacement  is  slight  or  considerable ; 
it  depends  also  upon  the  degree  of  injury  which  the 
spinal  marrow  has  sustained. 

Fractures  of  the  cervical  vertebrce,  —  Fractures  of 
the  cervical  vertebrae,  below  the  origin  of  the 
phrenic  nerve,  produce  paralysis  of  the  arms,  as  well 
as  of  the  lower  parts  of  the  body  ;  but  this  paraly- 
sis is  seldom  complete.  If  it  occurs  at  the  sixth  or 
seventh  vertebra,  the  patient  has  some  feeling  and 
powers  of  motion  ;  but  if  at  the  fifth,  little  or  none. 
Sometimes  one  arm  is  much  more  afiected  than  the 
other,  when  the  fracture  is  oblique,  and  the  axillary 
plexus  of  nerves  is,  in  consequence,  partially  influ- 
enced. Respiration,  in  these  cases,  is  difficult,  and 
is  performed  wholly  by  the  diaphragm,  the  power 
of  the  intercostal  muscles  being  destroyed  by  the 
accident.  The  abdomen  is  also  tumid  from  flatulen- 
cy, as  when  the  dorsal  vertebrae  have  sustained  in- 
jury. The  other  symptoms,  in  regard  to  the  lower 
extremities,  the  bladder,  and  the  sphincter  ani,  are 
the  same  as  in  fractures  of  the  vertebrae  below  the 
cervical.  Death  ensues  in  these  cases  in  from  three 
to  seven  days,  as  the  disease  happens  to  be  seated 


508 


INJURIES  OP  THE  SPINE. 


in  the  fifth,  sixth,  or  seventh  vertebra.  I  have 
scarcely  known  the  subject  of  this  injury  to  live 
beyond  a  week,  and  but  rarely  to  die  on  the  second 
day,  although  they  sometimes  die  so  early,  if  the 
fifth  cervical  vertebra  has  sustained  the  injury.  I 
have  already  stated,  that  in  fractures  and  displace- 
ments above  the  fourth  cervical  vertebra,  death  al- 
most instantaneously  follows.  The  longest  life  I 
have  known  after  such  an  accident  has  been  ten 
months. 

Dissection.  —  In  the  dissection  of  these  cases  the 
following  appearances  are  found :  the  spinous  pro- 
cess of  the  displaced  vertebra  is  depressed  ;  the 
articular  processes  are  fractured  ;  the  body  of  the 
vertebra  is  broken  throiigh  ;  for  it  but  rarely  hap- 
pens that  the  separation  and  displacement  occur  at 
the  intervertebral  substance.  The  body  of  the 
vertebra  is  usually  advanced  from  half  an  inch  to  an 
inch.  Between  the  vertebrne  and  the  sheath  of  the 
spinal  marrow,  blood  is  extravasated ;  and  frequently 
there  is  extravasation  of  blood  on  the  spinal  chord 
itself.  The  spinal  marrow  is  compressed  and  bruis- 
ed in  slight  displacements,  and  is  torn  through  when 
the  injury  has  been  very  extensive  ;  but  the  dura 
mater  remains  whole.  A  bulb  is  formed  at  each 
end  of  the  lacerated  spinal  marrow,  which  lacera- 
tion is  usually  produced  by  the  bony  arch  of  the 
spinous  process. 

A  most  interesting  case  of  this  accident  has  been 
published  by  Mr  Harrold,  an  intelligent  surgeon  at 
Cheshunt ;  and  a  preparation  made  from  the  case  is 
preserved  in  the  Museum  at  the  Royal  College  of 
Surgeons. 

The  outline  of  the  case  is  as  follows : 

Case, —  A  man,  twenty-eight  years  of  age,  was 


INJURIES  OF  THE  SPINE. 


509 


knocked  down  by  a  quantity  of  chalk,  which,  falling 
upon  him,  broke  his  spine  at  tlie  lower  part  of  the 
dorsal,  or  the  beginning  of  the  lumbar  vertebra. 

The  principle  upon  which  Mr  Harrold  proceeded 
Avas,  to  produce  union  of  the  bones,  by  preserving 
the  spine  perfectly  at  rest ;  and  to  effect  this  object 
the  patient  was  placed  in  a  fracture-bed,  which  per- 
mitted him  to  evacuate  his  bowels  without  disturb- 
ance. The  urine  was  drawn  off  daily  by  the  cathe- 
ter for  several  weeks;  after  which  time  he  was 
able  to  retain  from  a  pint  to  a  pint  and  a  half,  and 
to  discharge  it  when  he  pleased.  A  wound  was 
produced  upon  the  sacrum,  from  the  constant  press- 
ure of  his  body  upon  the  bed  ;  and  although  he  was 
insensible  of  it,  the  sore  gradually  healed. 

Symptoms.  —  At  the  end  of  six  months  his  state 
was  as  follows  :  His  back  was  straight,  flexible,  and 
apparently  as  strong  as  ever.  He  retained  and 
passed  his  urine,  but  probably  he  discharged  it  more 
by  the  action  of  the  abdominal  muscles  than  by  any 
contraction  of  the  bladder.  He  had  a  stool  once 
ip  three  or  four  days.  His  health  and  spirits  were 
good,  but  he  had  neither  sensation  nor  volition  in  the 
lower  extremities.  He  dressed  himself  entirely;  he 
let  himself  down  stairs  step  by  step.  He  died  after 
the  lapse  of  twelve  months,  wanting  nine  days,  from 
the  accident,  owing  to  a  sore  on  the  tuberosity  of 
the  ischium,  and  to  disease  of  the  bone. 

Emmination.  —  I  carefully  examined  the  prepara- 
tion, which  is  preserved  in  the  Museum  of  the  Col- 
lege, and  found  the  following  circumstances: 

The  bodies  of  the  first  and  second  lumbar  verte- 
brae had  been  fractured;  the  first  had  advanced,  and 
the  second  had  been  forced  backwards. 

The  fracture  had  united  by  ossific  matter,  which 
had  been  spread  over  the  fore  part  of  both  verte- 


510 


INJURIES  OP  THE  SPINE. 


brae  to  a  considerable  extent,  and  a  little  had  been 
deposited  upon  the  dorsal  vertebrae. 

The  spinal  canal  had  been  much  diminished  by  a 
portion  of  bone  forced  into  it  from  the  first  vertebra 
of  the  loins  ;  this  portion  of  bone  had  split  the  theca 
vertebralis  into  two,  and  divided  the  spinal  marrow 
almost  entirely  ;  a  bulbous  projection  of  the  spinal 
marrow  appeared  above  and  below  the  bone,  formed 
by  its  divided  extremities,  which  were  separated 
nearly  an  inch  from  each  other. 

Formation  of  ossific  matter,  —  Mr  Brookes  also 
had  a  preparation  in  his  late  excellent  anatomical 
collection,  of  fracture  of  the  spine  at  the  seventh 
and  eighth  dorsal  vertebra?.  The  person  had  lived 
sufficiently  long  for  a  great  deposit  of  ossific  matter 
to  have  formed  upon  the  anterior  and  lateral  part  of 
the  fractured  vertebi'se.  The  spinal  marrow  was 
almost  entirely  torn  through,  but  the  spinal  sheath 
remained.  Mr  Brookes  could  not  learn  how  long 
the  person  had  survived  the  accident.  j- 

As  to  the  treatment  of  these  cases,  I  fear  that 
whatever  maj  be  done,  the  majority  of  them  will 
prove  fatal. 

To  bring  the  spine  into  its  natural  form  by  exten- 
sion would  be  impossible,  if  it  were  attempted;  and 
even  if  that  object  were  attained,  it  would  scarcely 
be  practicable  to  preserve  it  in  its  situation,  as  the 
least  motion  would  again  displace  it.  Rest  will  be 
essential  to  ossific  union;  but  ossific  union  will  not 
save  the  patient  if  the  pressure  upon  the  spinal 
marrow  be  not  removed. 

Operation  by  Mr  H.  Cline.  —  Mr  Henry  Cline  was 
the  only  person  who  took  a  scientific  view  of  this  ac- 
cident. He  considered  it  to  be  similar  to  fracture 
with  depression  of  the  cranium,  and  to  require  that 


INJURIES  OF  THE  SPINE. 


511 


the  pressure  should  be  removed  ;  and  as  the  cases 
had  proved  so  uniformly  fatal,  he  thought  himself 
justified  in  stepping  out  of  the  usual  course,  with 
the  hope  of  preserving  life.  He  made  an  incision 
upon  the  depressed  bone,  as  the  patient  was  Ijing 
upon  his  breast,  raised  the  muscles  covering  the  spi- 
nal arch,  applied  a  small  trephine  to  the  arch,  and 
cut  it  through  on  each  side,  so  as  to  remove  the  spi- 
nous process  and  the  arch  of  bone  which  pressed 
upon  the  spinal  marrow.  The  only  case  in  wdiich 
he  tried  it  did  not  succeed ;  and  unfortunately  he 
did  not  live  to  bring  his  opinion  sufficiently  to  the 
test  of  experiment,  to  warrant  a  decided  judgment. 
He  was  blamed  for  making  this  trial.  I  am  not 
sure  that  he  would  have  been  ultimately  successful; 
but  in  a  case  otherwise  without  hope,  I  am  certain 
that  such  an  attempt  was  laudable.* 

In  those  cases  in  which  the  first  and  second  cervi- 
cal vertebrae  have  been  broken  and  displaced,  death, 
from  obstructed  respiration,  is  too  sudden  to  allow 
time  for  any  surgical  relief. 


INFLAMMATION  AND  ULCERATION   OF  THE  SPINAL 
MARROW. 

The  only  one  which  I  could  determine  to  be  of 
this  nature  by  dissection  was  the  following:  — 

Case,  —  A  gentleman  who  resided  about  eight 
miles  from  London,  had,  by  a  fall,  received  a  severe 
blow  upon  his  spine  ;  but  as  it  produced  no  immedi- 

*  I  beg  the  reader  to  observe  that  this  operation  is  not  mine ; 
that  I  have  expressed  some  doubts  of  its  ultimate  success  ;  but 
I  wish  the  trial  to  be  made,  as  the  only  means  of  deciding  posi- 
tively on  its  utility  ;  and  if  it  saves  only  one  life  in  an  hundred, 
it  is  more  than  I  have  yet  seen  accomplished  by  surgery.  —  A.C. 


512 


INJURIES  OP  THE  SPINE. 


ate  ill  effect,  he  thought  very  lightly  of  it.  Ingoing 
down  to  his  country  house  he  was  exposed  to  the  in- 
clemencies of  the  weather,  and  he  was  on  a  sudden 
seized  with  pain  in  his  hack,  and  paralysis  of  the 
lower  extremities,  retention  of  urine,  and  an  involun- 
tary discharge  of  fasces.  I  was  requested  to  see  him 
on  account  of  the  retention  of  urine,  and  went  daily 
for  a  length  of  time  to  Wimbledon  Common,  >vhere 
he  resided,  to  make  use  of  the  catheter.  For  sever- 
al weeks  his  symptoms  remained  unchanged,  except- 
ing that  now  and  then  the  integuments  of  the  sacrum 
gave  way,  and  required  great  attention  to  prevent  a 
dangerous  sore.  Towards  the  close  of  his  existence 
he  complained  of  a  sense  of  uneasiness  and  disten- 
tion at  the  upper  part  of  his  abdomen.  His  appe- 
tite failed  him  ;  he  rejected  his  food,  and  had  a  great 
deal  of  fever,  with  quick  pulse  and  profuse  perspira- 
tion.   He  sunk  gradually,  worn  out  by  irritation. 

I  removed  the  spinal  marrow,  and  have  it  preserv- 
ed in  the  collection  at  St  Thomas's  Hospital.  Upon 
opening  the  spinal  sheath,  a  milky  fluid  was  found 
within  it,  just  above  the  cauda  equina;  and  higher 
than  this,  for  the  space  of  three  inches,  the  spinal 
marrow^  was  ulcerated  to  a  considerable  depth,  and 
was  in  the  softened  state  which  the  brain  assumes 
when  it  is  rendered  semi-fluid  by  putrefaction.  All 
the  other  parts  of  the  body  were  healthy,  excepting 
the  bladder,  which  was  considerably  inflamed,  and 
exceedingly  extended  by  the  long  continued  reten- 
tion of  the  urine. 

In  a  case  similar  to  this,  it  will  be  necessary  to 
make  use  of  precautions  to  prevent  inflammation, 
by  cupping  or  by  leeches.  Blisters  should  be  applied  ; 
and  if  the  fever  still  continues,  a  seton  should  be 
made,  or  issues  be  opened,  to  prevent  the  continu- 
ance of  inflammation,  by  producing  and  supporting 
external  irritation. 


f 


NOTES. 


Fracture  and  displacement  of  the  vertebrae.  —  We  have  been 
enabled  by  the  politeness  of  Dr  J.  R.  Barton,  to  give  an  ac- 
count of  his  operation  on  the  Spine. 

His  views  relative  to  this  operation  are  very  ingenious  and 
deserving  of  consideration.  His  object  in  cutting  down  to  the 
vertebras  is  not  the  mere  elevation  or  removal  of  a  depressed 
or  fractured  portion  of  the  bone,  but  the  excision  of  as  many  of 
the  spinous  processes  as  are  exterior  to  the  angle  formed  by  the 
dislocation  of  the  vertebras.  This  he  thinks  will  allow  the  spi- 
nal marrow  to  curve  outwards  so  as  to  free  it  fi  cm  pressure, 
and  also  allow  matter  or  effused  blood  to  be  readily  discharged. 

J.  P.  was  received  into  the  Pennsylvania  Hospital,  Aug.  18, 
1824,  with  a  fracture  of  the  spine,  caused  by  a  fall  from  the 
mast  head  of  a  brig.  The  lower  part  of  the  trunk,  and  the  in- 
ferior extremities  were  totally  paralysed.  He  continued  in  this 
state  discharging  his  faeces  and  urine  involuntarily  until  the 
30th  of  Aug  ,  when  Dr  Barton  performed  the  following  opera- 
tion. An  incision  was  made  about  eight  inches  in  length  im- 
mediately over  the  injured  vertebrae.  He  found  the  spinous 
process  and  arched  portion  of  the  seventh  dorsal  broken  off  and 
depressed  on  the  spinal  marrow.  When  this  was  done  it  was 
ascertained  that  the  bodies  of  the  7th  and  8th  dorsal  vertebrse 
were  dislocated  from  each  other,  without  any  fracture  but  that 
above  mentioned.  Lint  was  laid  over  the  wound.  The  para- 
lysis not  being  immediately  relieved,  it  was  inferred  that  com- 
pression was  kept  up  by  blood  effused  within  the  spinal  canal, 
which  would  possibly  escape  with  the  suppuration  from  the 
wound. 

About  forty-eight  hours  from  the  time  of  operation  sensi- 
bility began  to  return  below  the  injured  vertebrae,  and  gradu- 
ally extended  towards  the  toes  until  the  third  day,  when  he  was 
attacked  with  a  violent  chill,  which  continued  notwithstanding 
65 


514 


NOTES. 


all  the  stimulating  medicines  given,  until  his  death,  which.oc- 
curred  in  twelve  hours  from  its  commencement. 

An  examination  was  made  next  day  to  ascertain  the  real  state 
of  the  spinal  column.  On  opening  the  thorax,  the  posterior 
mediastinum  was  found  filled  by  about  half  a  gallon  of  coagula- 
ted blood,  which  accounts  for  the  difficulty  of  respiration  espe- 
cially when  he  lay  on  his  back.  This  being  cleared  away,  the 
condition  of  the  vertebral  column  was  seen.  The  7th  and  8lh 
dorsal  were  injured  as  before  stated,  the  body  of  the  9th  was 
fractured,  and  blood  was  effused  throughout  the  spinal  canal. 

Fractures  not  united  —  Where  the  extremities  of  fractured 
bones  have  not  been  brought  into  proper  apposition,  have  been 
frequently  moved,  or  the  constitution  of  the  patient  is  very  deli- 
cate, we  find  after  the  lapse  of  a  very  considerable  time,  no 
bony  union  formed.  Instead  of  this  there  is  a  ligamentous 
substance  joining  the  pieces  of  bone  to  each  other,  yet  as 
this  allows  of  motion,  the  usefulness  of  the  limb  is  almost  en- 
tirely lost.  This  is  a  circumstance  attended  with  much  diffi- 
culty, and  frequently  is  considered  beyond  the  reach  of  surgery. 
The  method  adopted  to  induce  a  renewal  of  the  ossific  action, 
is  by  making  an  irritation  directly  on  the  fractured  portions. 
This  has  sometimes  been  done  by  rubbing  them  together  with 
considerable  violence,  sometimes  by  cutting  down  and  sawing 
off  the  ends  of  the  bone.  The  passage  of  a  seton  through  the 
limb,  between  the  ends  of  the  fracture,  has  been  very  successful 
in  the  hands  of  Dr  Physick  and  others.  Dr  J.  R.  Barton, 
lately  informed  me  of  a  case  in  which  he  had  succeeded  per- 
fectly in  restoring  the  limb  of  a  gentleman  whose  tibia  had  been 
broken  and  not  united  by  bone.  He  applied  caustic  alkali  di- 
rectly over  the  ligamentous  union  and  continued  it  until  this 
substance  was  destroyed.  The  ossific  action  immediately  en- 
sued and  the  limb  became  as  useful  as  before  the  Fracture.  1 
have  recently  dissected  the  arm  of  a  very  robust  black  man  who 
died  very  suddenly.  At  about  two  inches  below  the  wrist  there 
was  a  tumor  of  considerable  size,  that,  from  its  hardness,  and 
general  appearance,  was  supposed  to  be  an  irregular  callus, 
formed  where  there  had  been  a  fracture.  The  skin  was  not 
diseased,  nor  were  the  extensors  of  the  thumb  which  crossed 
the  tumor.  But  when  the  extensors  were  removed,  and  the 
tendons  of  the  longer  and  shorter  radial  extensors  of  the  car- 
pus and  supinator  longus  were  removed,  a  number  of  black 
holes  were  seen  passing  into  the  bony  tumor  of  the  radius, 
and  containing  a  quantity  of  thick  and  foul  black  matter. 
The  periosteum  surrounding  was  thickened  and  in  some  places 
sloughy.  The  radius  had  been  obliquely  fractured,  the  inju- 
ry beginning  at  an  inch  and  a  half  below  the  carpal  extremity 
of  the  radius,  and  crossing  the  radius  obliquely,  so  as  to  ter- 


NOTES. 


515 


minate  about  two  inches  and  a  half  below,  on  the  inner  side, 
and  a  free  motion  was  allowed,  as  the  extremities  were  merely 
united  by  ligament. 

This  injury  I  suppose  was,  during  the  life  of  the  patient, 
mistaken  for  a  sprain  or  some  not  very  serious  mischief;  in 
consequence  of  which  the  limb  was  frequently  moved,  and  the 
ossific  union  prevented:  otherwise,  in  a  system  appearing  so 
robust  and  healthy,  a  fracture,  properly  treated,  would  have 
been  solidly  united  in  a  short  time.  J.  D.  G. 


ON  THE  FORMATION  OF  THE  CAPSULAR  LIGAMENTS 
OF  THE  JOINTS. 

Anatomists  hitherto  have  uniformly  cosidered  the  capsular 
and  proper  ligaments  of  the  joints  as  similar  in  character,  and, 
like  the  latter,  being  merely  continued  from  a  point  of  origin 
on  the  extremity  of  one  bone  to  an  insertion  near  the  extremi- 
ty of  another.  By  the  proper  ligaments  1  mean  those  which 
are  solid,  fibrous  and  mostly  perpendicular,  resembling  the 
lateral  ligaments  of  the  knee  joint  and  those  from  the  fibula 
and  tibia  to  the  tarsal  bones. 

The  capsular  ligaments,  however,  must  be  separated  from 
the  proper  ligaments,  inasmuch  as  they  are  immediately  re- 
lated to  the  muscular  system,  being  formed  by  the  layers  of 
the  fasciae  which  sheathe  all  the  muscles,  or  fairly  encircle 
them. 

The  muscles  of  the  upper  part  of  the  body  and  all  the 
trunkj  not  excepting  the  heart,  are  contained  within  duplica- 
tures  of  the  fascia  superficialis.  The  same  fascia  forms  the 
capsular  ligament  of  the  shoulder  joint,  by  the  succession  of 
the  layers  forming  the  sheaths  for  all  the  muscles  about  the 
scapula  going  to  be  laid  out  over  the  joint,  and  by  their  aggre- 
gation constituting  the  thickness  of  this  capsule. 

The  fascia  lata  femoris  sheathes  all  the  muscles  of  the  in- 
ferior extremities,  and  the  duplicatures,  enclosing  the  mus- 
cles of  the  thigh,  form  the  great  capsule  of  the  hip  joint, 
as  minutely  described  in  my  Anatomical  Investigations  re- 
cently published.  On  the  same  principle  the  capsular  liga- 
ments throughout  the  body  appear  to  be  formed  from  the 
fasciae  sheathing  the  muscles.  For  the  details  I  must  refer 
to  the  work  above  named,  and  the  18th  No.  of  the  Philadel- 
phia Medical  and  Physical  Journal,  in  which  the  details  of  the 


4 


516 


NOTES. 


formation  of  the  capsular  ligament  of  the  shoulder  joint  will 
be  given. 

The  muscles  within  the  belly  and  pelvis  derive  their  sheaths 
from  the  fascia  interna  abdominis,  heretofore  called  fascia 
transversalis^  which  also  forms  the  ligaments  of  the  liver,  and 
bladder,  the  prostrate  fascia,  &c. 

Some  persons  in  speaking  of  the  fascia  sttperfcialis  state 
that  it  is  composed  of  condensed  cellular  membrane.  This  is 
correct  as  applied  to  its  ultimate  analysis,  but  not  when  we  ex- 
amine it  in  the  recent  subject.  It  is  equally  true  that  skin,  ten- 
don and  bone,  are  composed  of  cellular  texture,  but  we  only 
arrive  at  this  conclusion  by  a  long  and  careful  series  of  expe- 
riments. 

The  discovery  of  the  formation  of  the  capsular  ligaments 
by  a  thorough  analysis  of  the  fasciae,  leads  to  a  variety  of  im- 
portant conclusions  relative  to  their  physiology  and  pathology, 
and  gives  us  a  better  idea  of  their  relation  to  the  strength  of 
the  muscles,  whose  actions  are  all  moditied  by  the  manner  in 
which  they  are  sheathed  by  these  fasciae.  See  18th  No.  of 
Philadelphia  Medical  Journal. 

Diagnosis  of  Fractures. —  M  Lisfranc  has  proposed  the  use 
of  the  stethoscope  for  determining  the  presence  of  fractures, 
which  will  be  attended  with  considerable  advantage:  especi- 
ally in  such  cases  of  fracture  as  are  not  marked  by  any  very 
striking  displacement  of  the  limb,  and  where  nothing  but  the 
crepitus  could  enable  us  to  say  that  the  limb  was  not  dislocat- 
ed. He  has  given  very  full  directions  for  the  use  of  the  in- 
strument, which  have  been  republished  in  various  periodical 
journals  in  this  country.  They  may  be  found  in  the  Archives 
Generales  de  Medicine,  at  l^uU  length. 

Bones  of  Children.  —  Dr  J.  Rhea  Barton  has  given  a  very 
interesting  paper  in  the  4th  volume  of  the  American  Medical 
Recorder  on  certain  injuries  of  the  bones  of  children  by  which 
the  figure  of  the  limb  is  much  altered  from  the  bending  of  the 
bones  without  the  production  of  fracture.  Several  cases  are 
related  and  a  plate  delineating  the  appearance  of  the  limb  and 
of  the  deformity  of  the  bones  accompanies  the  description. 

J.  D.  G. 


JPJLolo 


PLATE  I 


Shows  the  positions  of  the  limb  in  the  different  dislocations 
of  the  thigh-bone,  and  in  the  fracture  of  the  cervix  femoris. 

Fig.  1. 

The  thigh-bone  dislocated  vpwards^  upon  the  dorsum  ilii. 

The  leg  shorter,  the  hip  projecting,  the  knee  turned  inwards, 
and  the  patella  at  least  two  inches  higher  than  the  other;  the 
foot  turned  inwards,  and  the  toes  resting  upon  the  metatarsal 
bones  of  the  other  foot ;  the  head  of  the  bone  is  thrown  back, 
and  the  trochanter  major  forwards. 

Fig.  2, 

The  dislocation  downwards^  in  the  foramen  ovale. 

The  leg  is  longer  than  the  other  ;  the  knee  is  advanced  and 
separated  from  that  on  the  sound  side  ;  the  toe  is  pointed  down  j 
the  heel  does  not  touch  the  ground  ;  the  body  is  bent  forwards. 

This  is  the  only  accident  of  this  joint  in  which  the  leg  is  longer. 

Fig.  3. 

Dislocation  in  the  ischiatic  notch. 

The  leg  is  shorter ;  the  patella  from  half  an  inch  to  an  inch 
above  the  other  ;  the  foot  slightly  turned  inwards  ;  the  great  toe 
rests  against  the  ball  of  the  great  toe  of  the  other  foot ;  the  leg 
is  with  difficulty  separated  from  the  other. 

In  thin  persons,  the  head  of  the  os  femoris  may  be  felt  a  lit- 
tle above  and  behind  the  acetabulum;  more  especially  if  the 
surgeon  rolls  the  knee  inwards. 

Fig.  4. 

Dislocation  of  the  os  femoris  upon  the  pubes. 

Prominence  at  Poupart's  ligament,  from  the  head  of  >the 
bone;  the  knee  turned  out,  and  widely  separated  from  the  oth- 
er ;  leg  a  little  shorter,  the  one  patella  being  about  an  inch  high- 
er than  the  other;  the  toe  touches  the  ground,  but  the  heel 
does  not  reach  it ;  the  knee  and  foot  turned  out. 

Fig.  5. 

Fracture  of  the  neck  of  the  thigh-bone. 

The  leg  shorter;  the  knee  turned  out;  the  patella  from  one 
to  two  inches  above  the  other,  and  sometimes  more;  the  foot 
is  generally  everted,  and  does  not  reach  the  ground  when  the 
other  leg  is  straight ;  the  leg  is  easily  drawn  to  the  same  length 
with  the  other,  and  then,  if  rotated,  a  crepitus  is  felt. 


PLATE  II. 


Shows  a  dislocation  into  the  foramen  ovale  which  had  never 
been  reduced,  and  beautifully  exhibits  the  resources  of  nature, 
in  forming  a  new  socket  for  the  head  of  the  bone,  and  allowing 
of  the  restoration  of  a  considerable  degree  of  motion^ 

A.  Right  and  left  ilium 

B.  Ischium 

C.  Pubes 

D.  Foramen  ovale 

E.  The  left  acetabulum 

F.  Sacrum 

G.  Os  femoris 

H.  The  new  acetabulum,  formed  in  the  foramen  ovale,  in  which 

the  head  of  the  thigh-bone  was  contained,  and  in  which  it 
was  so  completely  enclosed,  that  it  became  impossible  to 
remove  it,  unless  a  portion  of  the  new  socket  was  broken 
away.  It  was  lined  by  a  ligamentous  substance,  on  which 
the  head  of  the  bone  moved  to  a  considerable  extent 

I.  The  original  acetabulum,  situated  above  the  level,  and  to  the 

outer  side  of  the  new  cavity. 

Museum,  St  Thomas'^s  Hospital. 


Piiih^^7i,:d  hy  £tny&Wait.l832. 


J.Brayton  Sc. 


PLATE  III. 


Exhibits  another  view  of  the  same  preparation,  showing  the 
relative  situation  and  appearance  of  the  new  and  original  aceta- 
bulum. 

AA.  Ilia 

B.  The  original  acetabulum,  little  more  than  half  its  natural 

size,  the  edge  of  the  new  acetabulum  occupying  its  lower 
and  anterior  part 

C.  The  new  acetabulum  formed  in  the  foramen  ovale,  a  deep 

ossific  edge  surrounding  it ;  its  internal  surface  is  extremely 
smooth.  The  ligament  of  the  foramen  ovale  has  disappear- 
ed, and  ossific  matter  has  been  deposited  in  its  stead 

D.  The  thigh-bone  removed,  and  the  portion  of  the  new  aceta- 

bulum is  shown,  which  was  obliged  to  be  broken  off  to  se- 
parate the  thigh-bone  from  its  new  socket 
E«  Head  and  neck  of  the  thigh-bone;  the  former  a  little  changed 
by  absorption,  and  the  latter  by  ossific  deposit. 


PLATE  IV. 


Shows  a  dislocation  in  the  ischiatic  notch.  This  is  a  side  view 
of  the  exterior  surface  of  the  osinnorainatum. 

A.  Ilium 

B.  Ischium 

C.  Pubes 

D.  Trochanter  mnjor,  covering  and  concealing  the  acetahulum' 

F.  Head  of  the  os  femoris  thrown  into  the  ischiatic  notch,  and 

situated  between  the  posterior  and  inferior  spinous  process 
of  the  ilium,  and  the  spinous  process  of  the  ischium 

G.  A  new  capsular  ligament,  formed  around  the  head  of  the  hone, 

and  composed  of  cellular  membrane,  condensed  by  inflamma- 
tion 

H.  Ligamentum  teres,  which  had  been  torn  through  in  the  dis- 
location, as  well  as  the  original  capsular  ligament. 

Museum^  St  Thomases  Hospital, 


ipt-.:jt. 


i-uKlished    bv   LiUj   il   Wilt  Eciu.n  1832 


PLATE  V. 


Exhibits  a  view  of  the  dislocation  of  the  os  femoris  upon  the 
pubes,  or  forwards  and  upwards.  This  preparation  bejiutifuily 
shows  the  power  of  nature  in  accommodating  itself  to  new  cir- 
cumstances. 

AA.  Ilia 

B.  Pubes 

C.  Ischia 

D.  Os  femoris 

E.  Trochanter  major,  occupying  the  original  acetabulum 

F.  Head  and  neck  of  the  os  femoris,  upon  the  junction  of  the 
pubes  and  ilium 

G.  The  new  cup  formed  for  the  neck  of  the  os  femoris 

H.  The  femoral  artery  and  vein,  passed  upon  the  smooth  sur 
face  of  the  pubes,  on  the  inner  side  of  the  new  acetabulum. 

Museum^  St  Thomases  Hospital. 


66 


PLATE  VI. 


Shows  the  same  pelvis,  with  the  thigh-bone  removed  from  it, 
to  expose  the  new  acetabulum  formed  by  ossific  inflammation 
on  the  junction  of  the  pubes  and  ilium. 

AA.  Ilia 
BB.  Pubes 
CC.  Ischia 

D.  Acetabulum  which  was  occupied  by  the  trochanter  major 
EF.  The  new  acetabulum. 

Under  the  line  E.  the  femoral  artery  and  vein  took  their 
jcourse. 


■JFIL.:VILo 


Publibhod  bj- J.illj  i  \Vait.llos(on.li!32 


PLATE  VII 


Dislocation  and  fracture  of  the  pelvis. 

A.  Fracture  of  the  puhes  on  the  left  side 

B.  Fracture  of  the  ischium  on  the  same  side 

C.  Dislocation  of  the  right  ilium 

D.  Laceration  of  the  ilio  sacral  ligament,  and  separation  of  the 

ilium  from  the  sacrum. 


PLATE  VIII. 


Fig.  1. 

Shows  the  mode  of  reducing  the  dislocation  upwards^  on  the 
dorsum  ilii. 

A.  The  band  passed  between  the  thighs  to  fix  the  pelvis 

B.  The  pulley  fixed  above  the  knee,  and  the  direction  shown  in 

which  the  thigh  is  to  be  drawn;  viz,  obliquely  across  the 
sound  thigh,  two-thirds  of  its  length  downwards 

C.  Head  of  the  bone  upon  the  dorsum  ilii 

D.  Acetabulum. 

Fig.  2. 

Dislocation  in  the  foramen  ovale. 

A.  Bandage  to  fix  the  pelvis 

B.  The  pulley  to  draw  the  head  of  the  os  femoris  outwards  and 

upwards 

C.  The  surgeon''s  hand  grasping  the  ankle  to  draw  the  one  leg 

across  the  other,  and  to  throw  the  head  of  the  bone  outwards 

D.  Head  of  the  bone  in  the  foramen  ovale 

E.  Acetabulum,  into  which  the  head  of  the  bone  is  to  be  brought. 


\3 

K 


PLATE  IX. 


Fig.  3. 

This  is  a  view  of  the  mode  of  reducing  the  dislocation  into 
the  ischiatic  notch. 

A.  The  bandage  which  fixes  the  pelvis,  and  which  passes  be- 

tween the  thighs 

B.  The  pulleys  fixed  above  the  knee,  and  extending  in  a  direc- 

tion across  the  middle  of  the  sound  thigh 

C.  A  band  surrounding  the  thigh,  by  which  the  surgeon  is  to 

elevate  the  bone  when  the  extension  has  been  for  some 
time  continued 

D.  The  acetabulum 

E.  The  head  of  the  bone  in  the  ischiatic  notch. 

Fig.  4. 

This  figure  shows  the  best  mode  of  reducing  the  dislocation 
of  the  OS  femoris  upon  the  pubes. 

A.  The  bandage  to  fix  the  pelvis,  passing  upwards  and  forwards 

B.  The  pulleys  which  draw  the  bone  downwards  and  backwards 

C.  A  band  passed  around  the  thigh,  to  enable  the  surgeon  to 

raise  the  head  of  the  bone  during  the  extension 

D.  Head  of  the  os  femoris  on  the  pubes 

E.  The  acetabulum,  above  and  before  which  the  head  of  the 

bone  rests  upon  the  junction  of  the  pubes  and  ilium. 


V 


PLATE  X. 


Shows  fractures  of  the  neck  of  the  thigh-bone  in  man,  and  in 
other  animals,  as  they  usually  appear  on  dissection. 

Fig.  1. 

Ligamentous  union  shown. 

A.  Ilium 

B.  Pubes 

C.  Ischium 

D.  Foramen  ovale 

E.  Os  femoris 

F.  Trochanter  major 

G.  Trochanter  minor 

H.  Neck  of  the  thigh-bone  broken  within  the  capsular  liga- 

ment, and  in  a  great  degree  absorbed,  as  it  generally  is 
soon  after  the  accident:  its  surfiice  smooth  from  friction, 
and  rounded  to  roll  upon  the  hollow  of  the  head  of  the  bone 

I.  Head  of  the  bone,  hanging  in  the  acetabulum  by  the  ligamen- 

tum  teres  only,  smoothed  by  one  bone  rubbing  against  the 
other  :  a  portion  of  its  surface  having  ligament  secreted 
upon  it 

K.  The  capsular  ligament  exceedingly  thickened  ;  more  espe- 
cially on  that  part  of  the  joint  which  is  opposite  to  the  fo- 
ramen ovale. 

Fig.  2. 

A.  Ilium 

B.  Pubes 

C.  Ischium 

D.  Foramen  ovale 

E.  Os  femoris 

F.  Broken  cervix  femoris,  in  a  great  degree  absorbed 

G.  The  head  of  the  bone,  supported  by  the  ligamentum  teres, 

and  having  no  other  connexion  with  the  body :  its  surface 
smoothed  by  friction  when  the  person  begins  to  walk. 
In  each  of  these  preparations  the  head  and  neck  of  the  bone 
conjointly,  would  not  form  more  than  one-third  the  natural 
length  of  those  parts. 

Fig.  3. 

The  neck  of  the  bone  broken  in  a  dog,  and  no  union  produc- 
ed but  by  ligament. 

Fig.  4. 

The  neck  of  the  thigh-bone  broken  and  ununited  but  by  liga- 
ment. The  ligament  in  this  experiment  was  not  injured  in 
breaking  the  bone. 


FiMMH  Uayi^  If  ait.  1832. 


/ 


I 


PLATE  XI. 


Fig.  1. 

Shows  a  preparation  of  Mr  Langstaff 'a.  A  fracture  of  the 
thigh-bone  united,  as  it  usually  is,  by  ligament. 

A.  Head  of  the  thigh-bone 

B.  Trochanter  major 

C.  Trochanter  minor 

D.  Shaft  of  the  os  femoris 

E.  Capsular  ligament  excessively  thickened 

F.  Ligamentous  productions  uniting  the  neck  to  the  head  of  the 
bone 

G.  A  fork  formed  in  the  trochanter  minor,  which  received  the 
head  of  the  bone,  and  prevented  its  further  descent. 

Fig.  2. 

Shows  a  preparation  of  Mr  Langstaflf's.  The  upper  part  of 
the  thigh-bone  broken  within  the  capsule  and  external  to  it. 
That  external  to  the  capsule  firmly  united  by  bone,  and  that 
within  it  not  united. 

A.  Head  of  the  thigh-bone 

B.  Trochanter  major 

C.  Trochanter  minor  » . 

D.  Shaft  of  the  bone 

E.  Ligamentum  teres,  in  its  usual  situation  as  regards  the  head 
of  the  bone,  and,  as  will  be  seen,  not  at  its  centre. 

F.  Fracture  of  the  thigh-bone  external  to  the  capsule,  firmly 
and  well  united  by  bone 

G.  Fractured  cervix  within  the  capsule,  still  remaining  ununited, 
even  by  ligament. 


PubLUhfd  by  LW-i/ &  n'ait.IS^Z. 


Fzg.2 


'lucka-.Aifuii'Jm,. 


Jfuhlislz,:d  bif  Lilly  S.NaiL  1832. 


Sced.Sculp. 


L 


PLATE  XII.  ^^Im 

Contains  views  of  the  altered  state  of  the  neck  of  the  thigh- 
bone, by  which  it  is  rendered  incapable  of  supporting  the  super- 
incumbent weight  of  the  body,  gradually  becoming  absorbed,  and 
the  head  of  the  bone  descending  to  the  trochanter  minor. 

Fig.  1. 

Is  a  diagram  of  the  upper  part  of  the  thigh-bone,  to  show  the 
change  in  figure  it  undergoes  from  a  softened  and  absorbed  state 
of  its  cervix. 

A.  Natural  position  of  the  h  ad  of  the  bone 

B.  Head  of  the  bone  fallen  to  the  trochanter  minor 

C.  Shaft  of  the  thigh-bone. 

Fig.  2. 

Head  of  the  thigh-bone  fallen, —  neck  of  the  bone  absorbed 
and  shortened,  so  that  the  head  and  trochanter  are  brought 
together. 

A.  Head  of  the  bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone 

D.  Ligament  attached  to  the  remains  of  the  cervix. 

Fig.  3. 

Shows  in  a  section  the  internal  view  of  fig.  2.  The  cervix 
femoris  in  a  great  degree  absorbed,  the  head  of  the  bone  and 
trochanter  major  in  contact. 

A.  Head  of  the  thigh-bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone 

D.  Ligament  entering  between  the  head  and  cervix 

E.  Cervix  femoris  in  a  great  degree  absorbed.    This  disease 

occurred  on  both  sides  in  the  same  subject. 

Fig.  4. 

Section  of  the  head  and  neck  of  the  thigh-bone,  the  neck  in 
a  great  degree  absorbed. 

A.  Head  of  the  os  femoris 

B.  Trochanter  major 

CC.  Remains  of  the  cervix  and  ligament. 

Fig.  5. 

Head  and  neck  of  the  thigh-bone  sunken  down  an  inch  and  a 
quarter  towards  the  trochanter  minor  —  neck  of  the  bone  ab- 
sorbed, shortened,  and  a  line  formed  at  the  part  at  which  it  yields 
to  the  superincumbent  weight,  which  gives  it  the  appearance  of 
having  been  fractured;  wholly,  in  some  sections  of  it, — partially, 
in  others. 

A.  Head  of  the  thigh-bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone 

67 

% 


DD.  Line  of  absorption  of  the  phosphate  of  lime  ;  in  the  recent 
state  a  ligamento  cartilaginous  substance  is  found. 
I  have  several  sections  of  this  state  of  the  bone  ;  two  in  which 
the  line  of  absorption  extends  quite  through  ;  two  in  which  it 
extends  partially  through;  and  one  in  which  the  line  of  absorp- 
tion has  taken  quite  a  different  direction. 

Fig.  6. 

Shows  the  greatest  descent  of  the  head  of  the  thigh-bone  which 
I  have  seen.  —  Let  this  section  be  brought  in  comparison  with 
fig.  1,  and  the  great  alteration  which  it  has  undergone  will  be  at 
once  obvious  ;  the  head  of  the  bone,  instead  of  being  at  A,  is  at  B 
of  fig.  1,  pressed  down  by  the  superincumbent  weight  of  the  body. 

A.  Head  of  the  bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone. 

Thus  the  neck  of  the  thigh-bone  undergoes  great  changes  in 
form,  length,  and  direction. 

Fig.  7. 

Shows  the  changes  which  are  sometimes  found  in  old  and  bed- 
ridden persons. 

A.  Head  of  the  thigh-bone 

B.  Trochanter  major 

C.  Cancelli  of  the  neck  of  the  bone  increased  in  coarseness  by 

absorption,  so  as  to  render  the  bone  weaker,  and, when  dried, 
diaphanous 

D.  Piece  of  bone  added  to  the  upper  part  of  the  cervix 

EE.  A  larger  piece  of  bone  added  to  the  lower  part  of  the  cer- 
vix, to  support  the  weakened  neck  of  the  bone. 

If  sections  are  made  transversely  of  the  neck  of  the  thigh- 
bone in  old  persons,  the  neck  of  the  bone  is  found  so  exceedingly 
spongy,  as  to  be  unable  to  bear  even  slight  concussion. 

Fig.  8. 

Is  a  fracture  of  the  neck  of  the  thigh-bone  in  a  person  be- 
tween thirty  and  forty  years  of  age.  The  preparation  was  lent 
me  by  Mr  Herbert  Mayo. 

The  bone  was  siiortened  an  inch  only,  because  a  fork  in  the 
trochanter  minor  had  caught  the  neck  of  the  bone,  and  prevented 
its  further  descent.  The  person  lived  nine  months  after  the 
accident ;  and  although  the  age  was  ftn'ourable,  and  the  bones 
were  nearly  in  apposition,  ligamentous  union  only  was  produced. 

A.  Head  of  the  bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone 

D.  Fork  in  the  trochanter  minor 

E.  Fracture  united  oy  ligament  only. 

It  is  curious  to  observe  how  little  the  head  of  the  bone  is 
changed  in  this  fracture  after  nine  months.  Any  other  bones  in 
the  body  but  those  forming  parts  of  articulations  would  be  loaded 
with  ossific  matter. 


Sud.Sriilp. 


PLATE  XIII. 


Fig.  1. 

Fracture  of  the  cervix  femoris,  sent  me  By  Mr  Powell,  sur- 
geon of  Coram-street,  Brunswick-square,  in  which  the  neck  of 
the  thigh-bone  has  been  forced  into  the  cancellated  structure. 

A.  AcetabuluDf) 

B.  Head  of  the  thigh-bone 

C.  Trochanter  major 

D.  Trochanter  minor 

E.  Shaft  of  the  thigh-bone 

F.  Neck  of  the  thigh-bone  united  to  the  cancelli,  into  which  it 

had  been  forced 

G.  Addition  to  the  trochanter  major,  which  occasionally  rested 

on  the  ilium 

H.  Addition  to  the  trochanter  minor,  which  occasionally  rested 

on  the  left  of  the  acetabulum  ;  and  thus  the  bone  became 
supported  by  these  processes  under  the  weakened  state  of 
the  cervix. 

Fig.  2. 

Anatomical  view  of  the  head  of  the  thigh-bone  and  capsular 
ligament. 

A.  Head  of  the  thigh-bone 

B.  Thigh-bone 

C.  Reflected  synovial  surface,  vessels  seen  under  it 

D.  Depression  for  the  ligamentum  teres 

EE.  Capsular  ligament,  and  synovial  secreting  surface 

F.  Place  of  reflection  of  the  synovial  surface 

G.  Reflected  ligament  upon  the  neck  of  the  bone,  which  sinks 

into  its  pores  and  envelopes  the  neck  of  the  bone  as  a 
periosteum  ;  conveying  vessels,  but  differing  from  perios- 
teum in  the  strength,  arrangement,  and  appearance  of  its 
fibrous  structure. 

Fig.  3. 

A.  Head  of  the  bone 

B.  Ligamentum  teres 

C.  Thigh-bone 

D.  Trochanter  major 

E.  Trochanter  minor 

F.  Capsular  ligament 

GG.  Insertion  of  the  capsular  ligament  into  the  bone 


H.  A  band  of  reflected  ligament  and  synovial  secreting^  surface 
with  its  vessels  opposite  the  trochanter  minor.  Nearer  to 
the  bone  the  reflection  of  the  ligamentous  periosteum  is 
seen 

H.  Another  band  opposite  the  trochanter  major,  the  blood- 

vessels in  it 

I.  The  reflected  ligament  forming  a  sheath  to  the  bone  is  seen 

upon  the  cervix  femoris. 

In  reviewing  what  1  have  written  on  the  structure  of  the 
head  and  neck  of  the  thigh-bone,  I  fear  that  some  misconcep- 
tion may  be  formed  of  the  passage  in  which  I  say  that  the  head 
and  neck  of  the  bone  are  supplied  with  vessels  from  the  re- 
flected ligament  and  ligamentum  teres.  I  would  not  be  under- 
stood to  mean  that  this  is  the  only  supply,  for  it  is  well  known 
that  vessels  pass  through  the  interior  of  the  neck  of  the  bone  ; 
but  as  these  are  torn  through  by  the  fracture,  only  those  of  the 
untorn  reflected  ligament  and  ligamentum  teres  remain,  and  it 
is  principally  those  of  which  I  have  given  a  view  in  this  plate. 
In  the  fastal  bone,  in  this  plate,  the  interior  vessels  are  slightly 
tinted. 

Fig,  4. 

Faetal  thigh-bone. 

A.  Head  of  the  bone 

B.  Trochanter  major 

C.  Shaft  of  the  bone 

D.  Ligamentum  teres,  with  its  vessels 

E.  Ossific  vessels  of  the  head  of  the  bone. 

Fig.  5. 

Extremity  of  the  os  calcis,  cut  ofi"  and  drawn  up  by  the  ac- 
tion of  the  gastrocnemius  muscle,  in  the  rabbit. 

A.  Os  calcis 

B.  Portion  of  bone  detached  from  it 

C.  Union  by  ligament. 

Fig.  6. 

Longitudinal  section  of  the  head  of  the  thigh-bone  in  a  dog, 
partly  within  and  partly  external  to  the  ligament. 

A.  Head  of  the  bone 

B.  Portion  of  the  head  of  the  bone  broken  off  longitudinally, 

and  re-united  by  an  ossific  process.    In  this  experiment, 
both  the  capsular  ligament  and  periosteum  afforded  nour- 
ishment to  the  bone. 


PLATE  XIV. 


Fig.  1. 

Shows  the  seat  of  fracture  of  the  cervix  femoris  within  the 
capsular  Hgament. 

A.  Head  of  the  bone 

B.  Cervix  femoris 

C.  Capsular  ligament. 

^  Fig^.  2. 

Exhibits  the  seat  of  fracture  of  the  trochanter  major,  often 
mistaken  for  fractured  cervix  femoris.  This  fracture  unites  by 
bone. 

A.  Head  of  the  bone 

B.  Shaft  of  the  os  femoris 

C.  Fracture  through  the  trochanter. 

Fig.  3. 

Fracture  of  the  trochanter,  sent  me  by  Mr  Oldknow,  of  Not- 
tingham. 

A.  Head  of  the  bone 

B.  Broken  trochanter  major 

C.  Broken  trochanter  minor 

D.  Neck  of  the  thigh-bone 

E.  Shaft  of  the  bone. 

Fig,  4. 

Shows  the  bone  sent  me  by  Mr  Roux,  in  which  the  neck  of 
the  OS  femoris  is  driven  into  the  cancellated  structure  of  the 
shaft  of  the  bone,  where  it  unites  by  means  of  bone,  as  in  Mr 
Powell's  case. 

Fig.  5. 

The  inclined  plane  for  simple  fracture  of  the  thigh  and  tro- 
chanter major. 

A.  Frame  to  rest  upon  the  bed 

B.  Two  lateral  supporters  to  A 

C.  The  plane  for  the  thigh 

D.  The  plane  for  the  leg 

E.  The  joint. 

Two  boards  nailed  together,  with  the  inclination  as  described 
in  the  plate,  answer  nearly  the  same  purpose. 


Fig.  6. 

The  thigh-bone  fractured  below  the  trochanter  nninor,  and 
drawn  into  a  most  deformed  union  by  the  action  of  the  psoas  and 
iliacus  internus  muscles. 

Museum,  St  Thomas's  Hospital. 
Fig.  7. 

Dislocation  of  the  knee  from  ulceration  of  the  ligament,  with 
subsequent  anchylosis  of  the  tibia  forwards,  at  right  angles  with 
the  thigh-bone,  and  of  the  patella  to  the  thigh-bone. 

A.  Shaft  of  the  bone 

BC.  Tibia  projecting  forwards,  and  anchylosed  to  the  os  femoris. 

D.  Patella  anchylosed 

E.  Ligamentum  patellar. 

Amputated  by  Mr  Cline. 

Museum,  St  Thomash  Hospital. 
Fig.  8. 

Fracture  of  the  human  thigh-bone  through  the  trochanter 
major,  in  which  ossific  union  has  taken  place,  the  fracture  being 
external  to  the  ligament. 

A.  Fracture. 

This  case  shows  the  tendency  to  eversion  of  the  knee  and  foot 
in  this  injury,  and  the  necessity  for  guarding  against  it  by  atten- 
tion to  the  position  of  the  foot  during  the  union. 


PLATE  XV. 

The  thigh-bone  broken  just  above  its  condyles  and  united. 
Laceration  of  the  rectus  muscle,  and  great  overlapping  of  the 
bone. 

A.  Os  femoris 

B.  Tibia 

C.  Patella 

D.  Rectus  muscle  lacerated 

EE.  Os  femoris  broken  and  overlapping  but  united 

F.  Point  of  the  os  femoris  projecting  through  the  rectus  muscle, 

preventing  complete  extension,  and  exceedingly  limiting  the 

flexion  of  the  joint. 

In  Mr  Patey's  possession. 


PLATE  XVI. 


Fig.  1. 

Shows  an  anterior  view  of  a  dislocation  of  the  thigh  at  the 
knee-joint  outwards. 

A.  Muscles  of  the  thigh 

B.  Patella 

C.  External  condyle  of  the  os  femoris,  which  had  pushed  through 

the  ligaments  and  skin 

D.  One  semilunar  cartilage 

E.  The  other  semilunar  cartilage 

F.  Head  of  the  tibia 

G.  Leg 

HH.  Capsular  ligament. 

Fig.  2. 

Posterior  view  of  the  same  knee. 

A.  Muscles  of  the  thigh 

B.  Gastrocnemius 

C.  Sciatic  nerve 

D.  Popliteal  vein 

E.  Popliteal  artery 

F.  External  condyle,  which  had  torn  the  capsular  ligament  and 

muscles  posteriorly 
O.  Internal  condyle,  which  had  also  torn  the  ligament  and 
muscles 

H.  Torn  ligaments 

From  Mr  Oliver^  of  Brentford. 
Fig.  3. 

Shows  the  thigh-bone  in  a  compound  fracture  at  its  condyles 
into  the  knee-joint. 

Museum^  St  Thomases  Hospital. 
Fig.  4. 

Longitudinal  fracture  of  the  patella,  in  which  the  separation 
of  the  bone  is  very  slight,  yet  it  is  united  by  ligament  only. 

A.  Tendon  of  the  rectus  femoris 

B.  Ligamentum  patellae 

C.  Patella 

D.  Ligamentous  union. 

Drawn  by  Mr  Sylvester. 

Museum^ 


St  Thomas'' s  Hospital. 


Picblished  hj  Lilli/.^lfaitJSiZ. 


PLATE  XVII. 


Diflferent  views  of  fracture  of  the  patella. 

Fig.  1. 

Fracture  of  the  patella,  with  ligamentous  union  and  great 
separation  of  the  bone. 

The  extent  of  separation  depends  upon  the  degree  of  lacera- 
tion of  the  capsular  ligament,  and  of  the  tendons  of  the  vasti 
muscles  which  are  spread  over  it. 

A.  Upper  portion  of  the  patella  drawn  up  by  the  action  of  the 

rectus  and  vasti 

B.  Lower  portion  of  the  bone 

C.  to  A.  Original  ligament 

C.  to  B.  New  ligament,  which,  from  its  length,  excessively 
diminished  the  power  of  the  extensor  muscles. 

Fig,  2. 

Patella  of  a  dog  broken  and  united  by  ligament. 

Fig.  3. 
Patella  of  a  rabbit  broken. 
A.  Coagulated  blood  between  the  bones. 

Fig.  4. 
Patella  of  a  rabbit  broken. 
A.  The  blood  absorbed,  and  adhesive  matter  in  its  stead. 

Fig.  5. 

Patella  of  the  rabbit  broken  and  united  by  ligament ;  from 
A.  to  B.  • 

Fig.  6. 

Longitudinal  fracture  of  the  patella  in  the  dog. 

A.  One  portion 

B.  The  other. 

Ligament  seen  between  the  two. 

Fig.  7. 

Patella  broken  longitudinally,  so  that  there  is  no  separation, 
and  it  is  united  by  bone. 

A.  Rectus  muscle 

B.  Ligamentum  patellae 

C.  Longitudinal  fracture  united. 

By  its  side  is  seen  the  patella  separated  and  macerated,  and 
there  was  slight  ossific  union. 

All  in  the  Museum,  St  Thomas'^s  Hospital. 

68 


PLATE  XVIIL 


Fig,  1. 

Shows  the  dislocation  of  the  tibia  inwards  at  the  ankle-joint. 

A.  Malleolus  internus  of  the  tibia  thrown  on  the  inner  side  of 

the  astragalus 

B.  A  portion  of  the  tibia  split  off 

C.  Fibula  broken 

D.  Broken  portion  of  the  tibia  adhering  by  ligament  to  the 

fibula 

E.  Malleolus  externus  of  the  fibula,  with  the  broken  portion  of 

the  tibia  adhering  to  it 

F.  Astragalus  thrown  outwards. 

Museum^  St  Thomases  Hospital 
Fig.  2, 

Shows  the  dislocation  of  the  tibia  outwards  at  the  ankle-joint. 

A.  Tibia 

B.  Fibula 

C.  Os  Calcis 

D.  Fracture  of  the  tibia  at  the  malleolus  internus,  which  has 

become  reunited 

E.  Extremity  of  the  fibula  broken 

F.  Tibia  thrown  on  the  outer  side  of  the  articulatory  surface  of 

the  astragalus,  to  which  it  is  anchylosed. 

Museum^  St  Thomas'' s  Hospital. 
Fig.  3. 

Shows  a  fracture  of  the  tibia  and  fibula  at  the  ankle-joint,  sent 
to  me  by  my  friend,  Mr  Hammick,  Surgeon  of  the  Plymouth 
Naval  Hospital. 

A.  Tibia  fractured 

B-  Fracture  of  the  fibula 

C.  Astragalus 

E,  Shell  of  the  bone  surrounding  a  fragment  of  bone,  and  so 
completely  enclosing  it  that  it  could  not  be  removed,  and 
amputation  became  necessary. 

Fig.  4. 

The  fragment  of  bone  seen  separately. 


PLATE  XIX. 
Partial  dislocation  of  the  tibia  forwards,  at  the  ankle-joint. 
Fig.  1. 

A.  The  tibia  thrown  forward  over  the  os  naviculare 

B.  The  astragalus 

C.  New  articulatory  surface  of  the  tibia 

D.  The  portion  of  the  astragalus  behind  the  tibia. 

Fig.  2. 

Opposite  view  of  fig.  1. 

A.  The  tibia  thrown  forwards 

B.  New  articulatory  surface  of  the  tibia 

C.  Astragalus 

D.  Fibula  broken  and  reunited 

E.  Malleolus  externus  of  the  fibula 

F.  Astragalus  behind  the  tibia. 

Fig.  3. 

Comminuted  fracture  of  the  tibia  at  the  ankle-joint,  which 
rendered  amputation  necessary. 

A.  Astragalus 

BB.  Fibula  fractured 

CC.  Tibia  shattered  into  the  joint. 


PLATE  XX. 


Two  views  of  dislocation  of  the  astragalus,  in  the  case  of 
Mr  Downes,  in  whom  the  astragalus  sloughed  away.  The 
drawing  was  made  when  the  bone  began  to  loosen. 


PJL.XX . 


Publish..!,   l.y  Lilly       W  ait   B<.sion  Ib.l-J 


PLATE  XXI. 


Dislocation  of  the  os  humeri  in  the  axilla,  as  it  appears  in  the 
first  dissection  of  the  parts. 

A.  Clavicle 

B.  Scapula 

C.  Os  humeri,  with  the  biceps  before,  and  triceps  behind  the  bone 

D.  Subscapularis 

E.  Teres  major 

F.  Latissimus  dorsi 

G.  Pectoralis  major 

H.  Nerves  of  the  axillary  plexus  and  axillary  artery  and  vein 

which  are  seen  cut  across  at  the  lower  part  of  the  plexus; 
the  cutaneous  nerve  seen  passing  through  the  coraco  brachi- 
alis  muscle 

I.  Coracoid  process 

K.  Head  of  the  bone  dislocated  in  the  axilla 

L.  Capsular  ligament  and  tendon  of  the  subscapularis  muscle 
torn,  through  which  laceration  the  head  of  the  bone  escap- 
ed from  the  glenoid  cavity. 


PLATE  XXII. 


Fig.  1. 

Shows  the^ew  socket  which  has  been  formed  on  the  inner 
side  of  the  inferior  costa  of  the  scapula,  in  a  dislocation  of  the 
OS  humeri  into  the  axilla. 

A.  The  scapula 

B.  The  coracoid  process  of  the  scapula 

C.  The  glenoid  cavity,  with  the  acromion  above  it 

D.  The  new  socket  for  the  head  of  the  os  humeri. 

Fig.  2. 

Partial  dislocation  of  the  os  humeri  forwards.  This  drawing 
was  made  from  the  dissection  of  Mr  Patey,  Dorset-street. 

A.  Clavicle 

B.  Acromion 

C.  Coracoid  process 

D.  Scapula 

EE.  Os  humeri  —  head  of  the  bone  somewhat  altered 

F.  Glenoid  cavity. 

G.  New  smooth  cavity  for  the  head  of  the  os  humeri,  which 

extended  from  the  edge  of  the  glenoid  cavity  to  the  cora- 
coid process  of  the  scapula. 


JPI..XX11,. 


wm  ."1 


Published   by  Lilly  k  W-iit.  tiosiou  ISii 


I'iih/islu-d  by  LiUy,(-Kaa.  Vm. 


PLATE  XXIII. 


Fig.  1. 

Dislocation  of  the  os  humeri  forwards,  under  the  clavicle,  and 
behind  the  pectoral  muscle. 

A.  Clavicle 

B.  Scapula 

C.  Acromion 

D.  Glenoid  cavity  of  the  scapula,  from  which  the  os  humeri 

had  been  thrown ;  and  on  the  inner  side  of  this  cavity  is 
seen  the  coracoid  process 

E.  The  head  of  the  os  humeri,  with  the  tendon  of  the  biceps 

passing  over  it ;  the  head  of  the  bone  under  the  middle  of 
the  clavicle,  in  the  centre  of  the  scapula,  and  on  the  inner 
side  of  the  coronoid  process 

F.  Portions  of  the  new  ligament,  which  enclosed  the  head  of 

the  bone. 

Removed  from  a  patient  in  St  Thomas's  Hospital,  by  Mr 
Coleby. 

Museum^  St  Thomases  Hospital. 


PLATE  XXIV. 


Fig.  1. 

Shows  a  dislocation  of  the  os  humeri  in  the  axilla. 

A.  The  clavicle 
BB.  The  scapula 

C.  The  OS  humeri 

D.  The  biceps  flexor  cubiti 
EE.  Subscapularis  muscle 

F.  Laceration  of  the  capsular  ligament,  and  of  the  tendon  of  the 

subscapularis 

G.  Head  of  the  bone  thrown  on  the  inner  side  of  the  inferior 

costa  of  the  scapula. 

Fig.  2. 

Dislocation  of  the  ulna  and  radius  backwards. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Biceps  flexor  cubiti,  inserted  into  the  tubercle  of  the  radius 

E.  Brachialis  internus,  inserted  into  the  coronoid  process  of  the 

ulna 

F.  Triceps  extensor  cubiti,  inserted  into  the  olecranon 

G.  Internal  condyle  of  the  os  humeri 

H.  Olecranon  and  coronoid  process,  thrown  behind  the  articu- 

latory  surface  of  the  os  humeri ;  the  coronoid  process  is 
received  into  the  posterior  cavity  of  the  humerus. 

Museum^  St  Thomas's  Hospital. 


FullUhed  iy  LiUi/,  &  Wait.  1332. 


J.Braytcrn  S. 


PLATE  XXV. 


Fig.  1. 

A  dislocation  of  the  ulna  backwards. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Insertion  of  the  biceps  flexor  cubiti  into  the  tubercle  of  the 

radius 

E.  Olecranon  thrown  behind  the  os  humeri 

F.  Some  appearance  of  injury  to  the  internal  condyle  of  the  os 

humeri. 

Museum^  St  Thomas''s  Hospital. 
Fig.  2. 

Opposite  view  of  the  same  preparation. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Insertion  of  the  biceps  into  the  tubercle  of  the  radius 

E.  Olecranon  thrown  backwards 

F.  Head  of  the  radius,  which,  by  its  pressure  against  the  exter- 

nal condyle  of  the  os  humeri,  has  produced  a  socket  there 
for  itself. 

Fig.  3. 

Dislocatio7i  of  the  Radius.  The  bone  is  thrown  upon  the  ex- 
ternal condyle,  and  upon  the  coronoid  process  of  the  ulna. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Olecranon 

E.  Head  of  the  radius.    The  coronary  ligament  and  a  part  of 

the  interosseous  ligament  is  torn  through,  and  the  head  of 
the  bone  is  thrown  upon  the  coronoid  process  of  the  ulna, 
and  external  condyle  of  the  os  humeri. 

Museum^  St  Thomas'' s  Hospital. 

69 


PLATE  XXVI. 


Shows  a  dislocation  of  the  radius  backwards,  behind,  and  to 
the  outer  side  of  the  external  condyle  of  the  os  humeri. 

A.  Os  humeri 

B.  Radius 

C.  Ulna 

D.  Internal  condyle  of  the  os  humeri 

E.  Coronoid  process  of  the  ulna;  the  capsular  ligament  being 

opened  to  show  D  and  E 

F.  The  head  of  the  radius  dislocated  backwards  and  outwards 

G.  The  coronary  ligament  torn  through. 

Given  by  Mr  Poingdestre.    Drawn  by  Mr  Sylvester. 


Museum^  St  Thomas's  Hospital. 


f'ld'lish^d ?^?^Iiat/ ^ [Tart IS^-ii.    jDrayton  S^. 


JJLNesinitk  .V,- 


PLATE  XXVII. 


Fig.  1. 

Shows  a  fracture  of  the  external  condyle  of  the  os  humeri, 
still  disunited. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Fractured  external  condyle  within  the  ligament;  no  attempt 
made  to  unite  it;  the  broken  portion  unaltered 

E.  Head  of  the  radius. 

Museum.,  St  Thomas's  Hospital 
Fig,  2. 

Fracture  of  the  external  condyle  of  the  os  humeri,  and  of  the 
coronoid  process  of  the  ulna. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  Head  of  the  radius 

E.  External  condyle  fractured  externally  to  the  capsular  liga- 
ments; great  attempts  mnde  by  nature  to  unite  it,  and  the 
form  of  I  he  bone  changed 

F.  Coronoid  process  of  the  ulna  broken  off,  and  united  by  liga- 
ment only  to  the  ulna;  no  attempt  made  to  produce  os;sitic 
union.  This  portion  of  the  coronoid  process  was  seated 
within  the  capsular  ligament. 

Museum^  St  Thomas''s  Hospital. 

Fig.  3. 

Fractured  olecranon. 

A.  Os  humeri 

B.  Ulna 

C.  Radius 

D.  A  portion  of  the  triceps  extensor  cubiti 

E.  Olecranon  broken  and  drawn  up  by  the  triceps 

F.  Shaft  of  the  ulna  where  the  olecranon  is  broken  from  it 

G.  The  new  ligament,  which  has  joined  the  olecranon  lo  the 
ulna. 

Museum^  St  Thomas's  Hospital. 


PLATE  XXVIIL 


Shows  a  fracture  ot  the  inferior  extremity  of  the  radius,  and 
dislocation  of  the  ulna  forwards. 

A.  Radius 

B.  Ulna 

C.  Ligamentum  annulare  carpi 

D.  Ulna  thrown  forwards  upon  the  os  crbiculare 

E.  Broken  extremity  of  the  radius:  the  shaft  of  the  bone 
thrown  forwards,  and  the  lower  extremity  of  the  bone  re- 
maining in  its  natural  situation.  On  the  shaft  of  the  bone, 
just  above  the  fracture,  is  seen  the  attachment  of  the  pro- 
nator quadratus. 

Museum,  St  Thomas's  Hospital. 
Fig.  2. 

Shows  a  compound  dislocation  of  the  ulna  backwards,  with  a 
compound  and  comminuted  fracture  of  the  radius. 

A.  Radius 

B.  Ulna 

C.  Carpus 

D.  Ulna  dislocated  backwards,  being  thrown  behind  the  extre- 
mity of  the  radius 

E.  Fragments  of  the  broken  radius  extremely  comminuted  :  the 
tendon  of  the  extensor  carpi  radialis  brevior  torn  through. 

Museum,  St  Thomases  Hospital. 

Fig.  3. 

Dislocation  of  the  second  phalanx  of  the  finger  forwards,  and 
of  the  first  backwards. 

A.  First  phalanx 

B.  Second  phalanx 

C.  Third  phalanx 

D.  Dislocated  extremity  of  the  first  phalanx 

E.  Dislocated  second  phalanx 

F.  New  capsular  ligament  covering  the  ends  of  the  dislocated 
bones. 

Fig.  4. 

Compound  dislocation  of  the  first  phalanx  of  the  thumb. 

A.  Metacarpal  bone 

B.  First  phalanx  thrown  backwards 

C.  Second  phalanx 

D.  First  phalanx  dislocated 

E.  Tendon  of  the  flexor  longus  pollicis  torn  through. 

In  the  treatment  of  this  accident,  the  end  of  the  bone  is  to 
be  sawn  away. 

Museum^  St  Thomas''s  Hospital. 


TTCr.  3. 


FI&  .  2 


FIG-.l 


■  IDraytim 


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PutlisKed  by  Lilly  H  WalLBosbn.ieS?.  . 


PLATE  XXIX. 

Fig,  1. 

Shows  a  view  of  a  dislocation  of  the  os  humeri  into  the  axilla 
on  the  right  side. 

Fig.  2. 

Is  a  view  of  the  dislocation  of  the  os  humeri  forwards,  behind 
the  pectoralis  major,  and  under  the  clavicle. 

Fig.  3. 

The  bones  of  the  trunk,  showing  the  seats  of  dislocation  of 
the  clavicle  and  os  humeri. 

A.  Sternal  end  of  the  clavicle  thrown  upon  the  sternum 

B.  Scapular  end  of  the  clavicle  thrown  upon  the  spine  of  the 
scapula 

C.  Spine  of  the  scapula 

D.  The  glenoid  cavity 

E.  Coracoid  process 

F.  Head  of  the  os  humeri  thrown  into  the  axilla 

G.  Head  of  the  os  humeri  thrown  forwards  upon  the  second  rib 
under  the  clavicle,  and  upon  the  inner  side  of  the  coracoid 
process  in  the  dislocation  forwards. 

Fig.  4. 

Shows  the  situation  of  the  head  of  the  os  humeri,  when  dis- 
located backwards  upon  the  scapulae. 

A.  Dorsum  scapulae 

B.  Os  humeri 

C.  Head  of  the  os  humeri  on  the  dorsum  scapulae. 

Fig.  5. 

Shows  a  dislocation  of  the  astragalus  outwards. 

A.  Malleolus  externus 

B.  Astragalus  thrown  outwards :  the  foot  resting  upon  its  outer 
edge. 

Fig.  6. 

A.  Ulna  thrown  back 

B.  Radius  thrown  with  the  ulna 

C.  Hollow  above  the  elbow. 


PLATE  XXX, 


Fig.  1. 

Shows  the  mode  which  I  almost  constantly  pursne  of  reducing 
recent  dislocations  of  the  os  humeri,  by  placing  the  heel  in  the 
axilla,  and  by  extending  the  arm  either  from  above  the  elbow 
or  from  the  wrist. 

Fig.  2. 

Mode  of  reduction  by  the  pulley;  showing  the  manne**  iq 
which  the  scapula  is  fixed  by  a  bandage  which  receives  the  arm, 
and  the  pulleys  af)plied  above  the  elbow  ;  as  well  as  the  direc- 
tion in  which  extension  is  to  be  made  in  dislocation  in  the  axilla. 
If  the  dislocation  be  forwards  under  the  clavicle^  the  arm  must 
be  somewhat  lowered  to  avoid  the  coracoid  process. 

Fig.  3. 

Shows  the  mode  of  reducing  the  dislocation  downwards,  by 
the  knee  in  the  axilla. 


PLATE  XXXI, 


Fig.  1.  Shows  an  altered  state  of  the  neck  of  the  thigh-bone 
frona  disease,  which  might  be  mistaken  for  fracture  and  union. 
The  same  appearance  in  a  less  degree,  is  sometimes  seen  in  the 
tipper  part  of  the  thigh-bone  in  very  old  persons;  the  head  and 
neck  of  the  bone  falling  down  upon  its  shaft  at  the  trochanter 
minor,  and  the  neck  of  the  bone  absorbed. 

Fig.  2.  Fracture  of  the  cervix  scapulse. 

A.  Spine  of  the  scapula 

B.  Coracoid  process 

C.  Glenoid  cavity  broken  off  by  a  fracture  through  the  neck  of 

the  scapula. 

Fig.  3.  Fracture  of  the  acromion. 

 4.  Fracture  of  the  cervix  humeri. 

 5.  Fracture  of  the  internal  condyle  of  the  os  humeri. 

 6.  Fracture  of  the  external  condyle  of  the  os  humeri. 

 7.  Fracture  of  the  olecranon. 

  8.  Fracture  of  the  coronoid  process  of  the  ulna. 

 9.  Clavicle  bandage,  with  the  pads  under  the  axilla,  to 

throw  the  head  of  the  os  humeri  from  the  side  ;  used 

in  fractured  clavicle  ;  in  dislocations  of  that  bone  ;  and 

in  fracture  of  the  cervix  scapulae. 

 10.  Lateral  splints  for  fractures  of  the  elbow-joint. 

  11.  Back  splint  for  the  arm,  with  the  hinge  at  the  elbow, 

for  fractures  of  the  condyles  when  requiring  motion. 
  12.  Mode  of  reduction  of  the  thumb. 

  13.  Loop  used  for  the  foregoing  purpose,  called  by  sailors 

the  clove  hitch,  composed  of  two  circles,  with  the  ends 
between  them. 

  14.  Bandage  for  the  fracture  of  the  olecranon. 

  15.  Common  mode  of  bandaging  for  the  fractured  patella. 

 16.  Leather  strap  buckled  above  the  patella,  with  another 

strap  passing  under  the  foot,  which  I  employ  for  frac- 
tured patella. 

  17.  Long  splint  for  fractured  thighs.    Its  upper  part  rests 

against  the  pubes,  and  is  buckled  around  the  upper  part 
of  the  thigh.  The  splint  passing  down  on  the  inner  side 
of  the  thigh  and  leg,  with  a  screw  to  add  to  its  length,  and 
a  boot  attached  to  it  to  confine  the  splint  to  the  loot. 

 18.  Splint,  with  a  foot-piece  on  each  side,  for  dislocations 

and  fractures  at  and  near  to  the  ankle-joint. 

 19.  Bandage  used  in  the  case  related  by  Mr  Harris,  of 

Reading,  of  injury  to  the  upper  part  of  the  thigh-bone. 

A.  A  pad  buckled  around  the  pelvis,  to  support  the  trochanter 

B.  Wedge  to  support  the  thigh-bone 

C.  Foot  supporter 

D.  Portion  of  the  mattress  which  drew  out  to  slide  a  bed-pan 

under  the  patient. 


PLATE  XXXII. 


Fig.  1. 

Shows  the  union  of  the  radius  after  fracture,  and  a  ligament- 
ous union  of  the  ulna.  Mr  Cline  used  to  attribute  the  want  of 
union  in  such  cases,  to  the  muscles  drawing  the  bones  from  each 
other,  hence  the  pronator  quadratus  would  produce  this  effect  j 
in  the  os  humeri,  the  coraco  brachialis  would,  in  a  similar  man- 
ner, prevent  union.  Whatever  prevents  pressure  of  one  bone 
against  the  other,  will  have  a  tendency  to  produce  that  etfect. 
VVant  of  pressure  is  one  principle  of  non-union. 

A.  Radius 

BB.  Section  of  the  ulna 

C.  Interosseous  ligament 

D.  Pronator  quadratus  muscle 

E.  United  radius 

F.  Ulna  united  bj  ligament. 

Fig.  2. 

Fracture  of  the  cranium,  and  a  portion  of  bone  removed  by 
the  trephine, 

A.  Os  frontis 

B.  Parietal  bone 

C.  Large  aperture  in  the  skull  remaining  unfilled  except  at  its 

edges,  although  it  had  the  appearance  of  being  an  acci- 
dent of  ancient  date 

D.  Fracture  not  united. 

In  examining  these  cases,  I  have  found  that  the  pericranium 
has  been  much  thickened  at  the  aperture.  The  dura  mater 
greatly  thickened  beneath  the  openings,  and  a  ligamentous  sub- 
stance unites  the  dura  mater  to  the  pericranium.  Some  ossific 
matter  is  added  to  the  edge  of  the  opening  in  the  bone,  but  un- 
less the  opening  be  small,  it  is  rarely  filled  by  bone. 

Fig.  3. 

Tibia  united  after  fracture  ;  yet  in  these  cases  the  person 
walks  with  a  much  less  halt  than  would  be  expected  by  the  sur- 
geon who  had  not  witnessed  similar  examples. 
AA.  Tibia 

B.  Non-union  of  the  tibia 

CCC.  Fibula  enormously  enlarged  and  curved,  so  as  to  bring 
the  foot  near  to  the  axis  of  the  body.  The  upper  part 
of  the  fibula  little  less  than  the  tibia 

D.  Interosseous  ligament. 

A  lady  from  Salisbury,  whom  I  lately  saw,  walked  extremely 
well  across  my  room,  although  her  tibia  was  not  united  after 
fracture. 


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Pubiii-hed  by  W,iil:..Hoslon..l83'2, 


PLATE  XXXIII 


Fig.  1. 

Shows  the  radius  of  a  dog,  from  which  half  an  inch  of  bone 
had  been  removed,  it  had  not  united,  but,  from  the  appearance 
of  the  callus,  probably  would  have  united  had  the  animal  lived 
longer  than  two  months. 

AA.  Space  produced  by  the  removal  of  the  bone. 

Fig.  2. 

Portion  of  the  radius  removed,  an  inch  in  length.  Mode  of 
union  shown. 

AA.  Each  end  of  the  radius  united  with  the  ulna  only. 

Fig,  3. 

Two  inches  of  the  radius  removed.  A  ligamentous  union  of 
the  radius  to  the  ulna  was  produced,  an.d  the  ulna  was  enlarged 
opposite  to  the  space  produced  by  the  removal  of  the  radius. 

Fig.  4. 

Is  a  curious  result  of  an  experiment,  in  which  an  inch  of  bone 
was  removed  from  the  radius,  and  the  ulna  was  accidentally 
broken  at  the  time.  The  radius  produced  callus,  which  did  not 
reach  from  bone  to  bone,  but  the  ulna,  at  its  fractured  part,  sent 
in  two  portions  of  bone  to  fill  the  space  between  the  ends  of 
the  radius. 

AA.  Space  between  the  ends  of  the  radius 

BB.  Fracture  of  the  ulna,  with  two  portions  of  bone  proceeding 
into  the  interspace  of  the  radius. 

This  experiment  explains  the  cases  of  apparent  union  between 
remote  portions  of  bone,  when  a  piece  of  the  tibia  has  been  re- 
moved, and  the  fibula  at  the  same  time  fractured  ;  this  is  fully 
exemplified  in  the  case  published  by  Mr  Dunn,  a  very  intelligent 
surgeon  at  Scarborough,  who  has  had  the  kindness  to  send  me  a 
cast  of  the  leg  of  his  patient. 

70 


PLATE  XXXIV 


Fig.  1. 

Shows  a  dislocation  of  the  scapular  end  of  the  clavicle  upon 
the  acromion ;  the  clavicle  is  seen  projecting  over  the  spine  ©f 
the  scapula. 

AA.  Clavicle 

B.  Scapula 

C.  Spine  of  the  scapula 

D.  Acromion 

E.  Scapular  end  of  the  chwicle  thrown  over  the  acromion 

F.  The  coronoid  ligament  almost  entirely  converted  into  bone, 

and  anchylosing  the  clavicle  to  the  scapula. 

Fig.  2. 

Shows  a  fracture  of  the  acromion  united  by  ligament. 

A.  Portion  of  the  scapula 

B.  Spine  of  the  scapula 

C.  Glenoid 

T).  Coracoid  process 

E.  Acromion 

F.  The  fracture  of  the  acromion  united  at  its  edge  by  the  liga- 

ment 

G.  Which  has  been  turned  aside  to  show  ligamentous  granula- 

tions upon  the  broken  surfaces. 

Fig.  3. 

Is  a  very  curious  preparation  of  dislocation  of  the  os  humeri  in 
the  axilla,  and  fracture  of  the  cervix  within  the  capsular  liga- 
ment, forming  there  a  new  joint,  the  fracture  not  having  united. 

AA.  The  scapula 

B.  Portion  of  the  clavicle 

C.  Acromion 

D.  Coracoid  process  of  the  scapula 

E.  Acromio-coracoid  ligament 

F.  Head  of  the  os  humeri  dislocated 

G.  Tubercles  of  the  os  humeri 

H.  Os  humeri 

I.  Tendon  of  the  biceps 

K.  The  new  joint  from  the  fracture. 

Fig.  4. 

Fracture  of  the  os  humeri  below  the  capsular  ligament  united. 

A.  Head  of  the  os  humeri 

B.  Os  humeri 

CC.  Fracture  united. 


